Efficacy of Dequalinium Chloride vs Metronidazole for the Treatment of Bacterial Vaginosis: A Randomized Clinical Trial

Importance

Bacterial vaginosis (BV) is a common cause of vaginal infection. First-line treatments of BV are metronidazole and clindamycin. Due to the increase in antibiotic resistance, effective nonantibiotic treatments for BV are needed.

Objective

To examine whether dequalinium chloride, a broad-spectrum antiseptic, is noninferior to oral metronidazole for the treatment of BV.

Design, Setting, and Participants

This phase 4, multicenter, triple-blind, double-dummy, parallel, noninferiority randomized clinical trial was conducted from July 29, 2021, to August 25, 2022, with a 1-month follow-up. Participants were premenopausal women 18 years or older with BV from 11 gynecologic practices and 1 hospital in Poland, Slovakia, and the Czech.

Intervention

Patients were randomized to treatment with dequalinium chloride vaginal tablets (10 mg once daily for 6 days) or oral metronidazole (500 mg twice daily for 7 days). Double-dummy medication kits contained vaginal and oral tablets with placebo and active medication.

Main Outcomes and Measures

The main outcome was the noninferiority margin (of 15 percentage points) in the absolute difference in clinical cure rates between dequalinium chloride and metronidazole 7 to 11 days after start of treatment (visit 1). Noninferiority was met if the lower 95% CI for the difference in clinical cure rate was less than 15 percentage points at visit 1.

Results

A total of 147 women (mean [SD] age, 36.7 [9.0] years) were treated with dequalinium chloride (n = 72) or metronidazole (n = 75). The clinical cure rates at visit 1 were 64 of 69 (92.8%) for dequalinium chloride vs 69 of 74 (93.2%) for metronidazole in the intention-to-treat population, whereas in the per-protocol population, cure rates were 54 of 58 (93.1%) for dequalinium chloride vs 48 of 53 (90.6%) for metronidazole. The treatment differences of -0.5 percentage points (95% CI, -10.8 to 9.8 percentage points; P = .002) in the intention-to-treat population and 2.5 percentage points (95% CI, -9.4 to 14.4 percentage points; P = .001) in the per-protocol population confirmed the noninferiority of dequalinium chloride. The tolerability of dequalinium chloride was rated as very good by 30 of 50 patients (60.0%) but only by 21 of 54 (38.9%) for metronidazole. Three patients in the metronidazole group suspended treatment due to an adverse event.

Conclusions and Relevance

This randomized clinical trial showed that dequalinium chloride was not inferior to metronidazole for the treatment of BV. Dequalinium chloride had a similarly high cure rate but with better tolerability and fewer adverse events. With a similar efficacy to metronidazole and clindamycin, dequalinium chloride warrants consideration as first-line treatment for BV to help reduce antibiotic consumption.

Trial Registration

EudraCT: 2020-002489-15.

COMPARISON OF THE IMPACT OF ANTISEPTIC AGENTS ON GARDNERELLA VAGINALIS AND ATOPOBIUM VAGINAE DETECTED IN THE ORAL CAVITY OF WOMEN WITH BACTERIAL VAGINOSIS

When women with comorbid bacterial vaginosis visit periodontologist, it is essential to understand the presence of cross-infection processes between the oral cavity and vagina in this particular category of subjects. Conducting detection of Gardnerella vaginalis and Atopobium vaginae, which are provocative microbial factors for bacterial vaginosis, is a mandatory step in the laboratory examination of subjects. When choosing an antiseptic for oral cavity disinfection, the use of 0.25% dequalinium chloride is more advisable. Both subjective and objective examination methods thoroughly demonstrate the higher clinical effectiveness of 0.25% dequalinium chloride: patients report a 20% more frequent improvement in subjective indicators, the index assessment of periodontal status improves by 1.2-1.6 times, and the detection rate of Gardnerella vaginalis and Atopobium vaginae is by 20% lower compared to 0.2% chlorhexidine. The specific composition of oral microbiota in this group of subjects necessitates adjustments to treatment protocols and consideration of the specific impact on Gardnerella vaginalis and Atopobium vaginae.

Dequalinium for bacterial vaginosis

Bacterial vaginosis is an infection characterised by overgrowth of anaerobic bacteria in the vagina with an accompanying loss of lactobacilli, and is thought to be the most common cause of abnormal vaginal discharge in women of child-bearing age.¹ Standard treatment for symptomatic bacterial vaginosis consists of a short course of an oral or topical antibiotic.² Dequalinium, a topical antiseptic agent, has been available for many years as a treatment for oral infections.³ A new formulation, dequalinium 10mg vaginal tablets (Fluomizin-Kora Healthcare), was licensed in the UK in June 2015 for the treatment of bacterial vaginosis.⁴ Here, we review evidence for the effectiveness and safety of dequalinium vaginal tablets in the management of bacterial vaginosis.

Plasmodium berghei: In vitro and in vivo activity of dequalinium

Bisquinoline compounds have exhibited remarkable activity in vitro and in vivo against Plasmodium parasites by inhibition of heme detoxification. We have tested the ability of dequalinium 1,1'-(1,10-decanediyl)bis(4-amino-2-methylquinoline), a known antimicrobial agent, to inhibit beta-hematin synthesis using a non-emzymatic colorimetric assay and globin proteolysis by electrophoretic analysis (SDS-PAGE-15%). Dequalinium was able to inhibit both processes in vitro with close correlation to a murine malaria model, reducing parasitemia levels, prolonging the survival time post-infection and curing 40% of infected mice using a combination therapy with a loading dose of chloroquine. These results confirm that dequalinium is a promising lead for antimalarial drug development.

[Treatment of urogenital infections in lower part of the genital organs in pregnant women which are at risk of miscarriage]

Urogenital infection being one of etiological factor of the development of miscarriage, physicians regard carrying out complex microbiological diagnostics of pregnant women which are at risk of miscarriage to be very important as well as providing appropriate therapy for women with urogenital infection. The study aimed at investigating the efficacy of local antimicrobial medication Fluomisin in complex treatment of pregnant women which are at risk of miscarriage. Obtained results confirm Fluomisin to be effective, safe and convenient at use-for pregnant women with inferior urogenital infections.

Local treatment of vaginal infections of varying etiology with dequalinium chloride or povidone iodine. A randomised, double-blind, active-controlled, multicentric clinical study

This randomised, double-blind, multicentric clinical study compared the efficacy and tolerability of the two vaginal antiseptics, 10 mg dequalinium chloride (CAS 522-51-0, Fluomycin N) and 200 mg povidone iodine (CAS 25655-41-8), in a parallel-group design. A total of 180 patients with vaginal infections of varying etiology participated in this study (bacterial vaginosis, fluor vaginalis, vulvo-vaginal candidiasis, trichomoniasis). Patients were randomly allocated to one of the two treatment groups and were treated once per day for 6 days. Control examinations took place 5 to 7 days after the end of treatment, and 3 to 4 weeks after the first control examination. The total symptoms score, a summary score for the clinical symptoms, discharge, burning, pruritus, redness of vulva/vagina, was defined as primary efficacy parameter. The treatments at the first control examination were compared in the full analysis set using the Wilcoxon-Mann-Whitney U-test, 2-sided, thereby proving equivalence of both treatments at the 5% level. Both treatments strongly improved the symptoms of vaginal infections both on short-term and long-term follow-up. Descriptive analysis of the secondary parameters, vaginal pH, degree of purity of the vaginal flora, and number of lactobacilli in the wet mounts, supported the comparable efficacy of both therapies to restore the vaginal milieu. Analysis of the diagnostic subgroups indicated that irrespective of the diagnosis, both treatments improved the efficacy criteria as observed for the entire population. The global assessment of the therapeutic efficacy by investigators and patients supported the results of the efficacy analysis with good to very good ratings in 70-90% of the cases. A good tolerability of both preparations was observed in this study with a low number of adverse events in the test group (5.8%).

Delocalized lipophilic cations selectively target the mitochondria of carcinoma cells

Traditional chemotherapies, aimed at DNA replication in rapidly dividing cells, have achieved only limited success in the treatment of carcinomas due largely to their lack of specificity for cells of tumorigenic origin. It is important, therefore, to investigate treatment strategies aimed at novel cellular targets that are sufficiently different between normal cells and cancer cells so as to provide a basis for selective tumor cell killing. Delocalized lipophilic cations (DLCs) are concentrated by cells and into mitochondria in response to negative inside transmembrane potentials. The higher plasma and/or mitochondrial membrane potentials of carcinoma cells compared to normal epithelial cells account for the selective accumulation of DLCs in carcinoma mitochondria. Since most DLCs are toxic to mitochondria at high concentrations, their selective accumulation in carcinoma mitochondria and consequent mitochondrial toxicity provide a basis for selective carcinoma cell killing. Several of these compounds have already displayed some degree of efficacy as chemotherapeutic agents in vitro and in vivo. The effectiveness of DLCs can also be enhanced by their use in photochemotherapy or combination drug therapy. Discovery of the biochemical differences that account for the higher membrane potentials in carcinoma cells is expected to lead to the design of new DLCs targeted specifically to those differences, resulting in even greater selectivity and efficacy for tumor cell killing.

[Microbiology of acute pharyngitis and acute tonsillitis and treatment with Taileqi troches]

A qualitative analysis of microflora from pharynx of 100 cases of acute pharyngitis and acute tonsillitis was performed. These patients were randomly divided into two groups so as to assess treatment effect of Taileqi troches vs Amoxycillin. Results showed that beta-hemolytic streptococcus, Klebsiella pneumoniae, staphylococcus aureus were the most common organisms causing diseases. The predominant anaerobic organisms were bacteroides melaninogenicus, eptostrep. These findings suggest that anaerobic bacteria may play a pathogenic role in infection of the pharynx. The effective rate of treatment with troche alone were 86 percent, roughly consistent with Amoxycillin group. No adverse effect was observed.

Failure to enhance the in vivo killing of human ovarian carcinoma by sequential treatment with dequalinium chloride and tumor necrosis factor

Dequalinium chloride (DECA) is a cationic, lipophilic compound with structure similar to the dye rhodamine 123. DECA is selectively accumulated and retained within the mitochondria of carcinoma cells where it acts as a mitochondrial poison by blocking mitochondrial enzymes which can then disrupt cellular energy production, eventually resulting in cell death. In this manner it is similar to the antimitochondrial effects observed with tumor necrosis factor (TNF). We have previously shown that DECA can synergize the in vitro antitumor effects of TNF against a panel of human ovarian cancer cell lines. Those drug studies have been extended to a xenogenic tumor system with a resultant increase in animal survival. Athymic mice were injected intraperitoneally with 2.0 x 10(7) PA-1 human ovarian cancer cells and DECA +/- TNF treatments begun either on Days 3 or 7 postinjection. Peritoneal tumor implantation was not histologically confirmed by Day 3 postinjection but confirmed by Day 7 following tumor cell injection. Single-agent DECA (5 mg/kg; qod) increased animal survival by 37% (P = 0.002) whereas recombinant human TNF (0.5 micrograms/mouse; qod) only increased survival by 13% (P = 0.27) relative to control animals for those animals treated 3 days post-tumor-injection. Sequential DECA/TNF enhanced animal survival by 45% (P = 0.0002) in similarly treated animals. When drug treatment was initiated 7 days following tumor injection, DECA increased survival by 23% (P = 0.04) while TNF had no effect on prolonging animal survival (3% increase; P = 0.79). Combination DECA/TNF increased survival by 23% (P = 0.04). In the UCI-101 ovarian tumor model, single-agent DECA increased survival by 28% (P = 0.04) while TNF treatment stimulated tumor growth (11% decrease in survival; P = 0.006). Combination DECA + TNF resulted in a 41% increase in survival (P = 0.003). No statistical differences were detected between survival rates for single-agent DECA vs DECA + TNF except for the UCI-101 tumor which showed potentiation due to the in vivo stimulatory effects of TNF.

Effect of dequalinium on K1735-M2 melanoma cell growth, directional migration and invasion in vitro

Cationic lipophilic compounds have an antiproliferative effect on certain tumour systems in vitro and in vivo. We have investigated whether the cationic lipophilic compound dequalinium affects not only proliferation but also motility and invasion of the highly metastatic and highly invasive melanoma cell line K1735-M2. Proliferation was assessed in monolayer cultures and in multicellular spheroids, motility was estimated in the assay of directional migration, and invasiveness was tested through confrontation cultures of tumour multicellular spheroids with embryonic chick heart tissue evaluated by computerized image analysis. 2 mumol/l dequalinium impaired melanoma cell proliferation, reduced directional migration and significantly blocked invasion in vitro. On the ultrastructural level, dequalinium caused obvious changes in mitochondria of both melanoma and embryonic chick heart cells. The mechanisms of the antiproliferative, antimigrating and antiinvasive effects remain to be determined. Inhibition of protein kinase C, calmodulin antagonism, DNA intercalation and/or direct effects on mitochondrial functions may be considered.

[Effects of dequalinium chloride and sanguinarine on the ultrastructure of early supragingival plaque]

The influence of antimicrobial mouthrinses containing dequalinium chloride or sanguinarine on early plaque formation was assessed in vivo in a clinical-experimental study. Rinses with water served as controls. After 24 and 72 hours, plastic films, which were applied to the buccal surfaces of six upper front teeth at the start of experiment, were removed and processed for transmission electron microscopic study. Dequalinium chloride or sanguinarine applied on plaque resulted in an increased and higher structured surface coating. Degenerated microorganisms were observed and the variety of bacteria seemed to be reduced. Both mouthrinses effected the early supragingival plaque formation. The effect of sanguinarine was more intensive than that of dequalinium chloride.

[The efficacy of dequalinium chloride/benzalkonium chloride as well as medicinal plants on the gingiva]

A comparative study involving 50 patients of both genders was conducted in order to determine the effect of dequalinium chloride/benzalconium chloride mouthrinse (Dequonal), and of a preparation of herbal essences (Parodontax) on gingival health. Each of the mouthrinses was used during four weeks by a group of 25 patients who were instructed to abstain from any other oral hygiene measure during this period. Approximal plaque index, sulcus bleeding index and saliva pH were significantly enhanced by both preparations. A slightly better effect shown by dequalinium chloride/benzalconium chloride was not significant.

Study of the selective cytotoxic properties of cationic, lipophilic mitochondrial-specific compounds in gynecologic malignancies

Cationic lipophilic compounds have a unique cytotoxic mechanism of action which is dependent on mitochondrial-specific localization of these fluorescent dyes. We have demonstrated in vitro that carcinoma cells, which have a higher negative mitochondrial membrane potential than normal cells, have an increased accumulation and retention of two of these compounds. The compounds tested were rhodamine 123 and dequalinium (DECA). After the development of a reproducible murine intraperitoneal (ip) human ovarian cancer model, which maintained the biologic characteristics of the parent cell line, we undertook in vivo evaluation of DECA. Mice with intraperitoneal tumor inoculations were treated with cisplatin, and/or DECA. When compared to cisplatin, a chemotherapeutic agent known to be effective in the treatment of clinical ovarian cancer, DECA was significantly more efficacious and seemed less toxic in the murine model. Cisplatin and DECA used together were possibly synergistic. Cationic lipophilic compounds may prove to be an exciting new class of antineoplastic agents which exploit intracellular, mitochondrial differences between normal cells and cancer cells.

Cutaneous trichosporosis

Of 269 patients with cutaneous trichosporosis a majority of 170 (63.2%) showed the infection as intertrigo in the genitocrural and perianal areas. The predominant symptoms were itching and burning. Trichosporosis has been found to be less common in the other sites. Trichosporosis due to Trichosporon beigelii should be kept in mind as one of the differential diagnosis in cases of genitocrural intertrigo and other cutaneous infections by fungi and bacteria in the tropics.

Dequalinium, a topical antimicrobial agent, displays anticarcinoma activity based on selective mitochondrial accumulation

Positively charged lipophilic compounds, such as rhodamine 123, localize in mitochondria and are selectively accumulated and retained by carcinoma cells. It has been suggested that this phenotype may be exploited for selective killing of carcinoma cells by lipophilic cations. Here we report that doubly positively charged dequalinium, which has been used for 30 years as an antimicrobial agent in over-the-counter mouthwashes, lozenges, ointments, and paints, exhibits significant anticarcinoma activity. Dequalinium is more effective than seven of eight established anticancer drugs in prolonging the survival of mice with intraperitoneally implanted mouse bladder carcinoma MB49. Dequalinium also inhibits the growth of subcutaneously implanted human colon carcinoma CX-1 in nude mice and recurrent rat colon carcinoma W163 in rats. Lipophilic cationic compounds, such as dequalinium, could comprise a unique class of anticarcinoma agents.

Inhibition of rat colon tumor isograft growth with dequalinium chloride

In searching for a new approach to the systemic treatment of colorectal carcinoma, we have observed that certain lipophilic cationic compounds are accumulated and retained for a significantly longer period in the mitochondria of living carcinoma cells than in normal cells or sarcoma cells. We report the in vivo therapeutic effect of one of these compounds, dequalinium chloride, on the W163 rat colon carcinoma isograft, which grows rapidly in Wistar/Furth rats after primary tumor implantation, and which recurs rapidly after primary tumor resection. In the primary transplant model, tumors were implanted, and daily dequalinium chloride treatments were begun the following day in doses ranging from 1 to 10 mg/kg. In the recurrence model, isografts were implanted, allowed to grow for one week, and then all gross tumor was resected. Dequalinium chloride was administered in varying daily doses starting the day after resection. In both models, tumor was removed on day 11 after implantation or resection. At sublethal doses, dequalinium chloride significantly inhibited primary tumor growth to 60% that of controls and recurrent tumor growth to 50% that of controls. We propose that this unique biologic approach of targeting carcinoma mitochondria with lipophilic cationic compounds may provide a major new opportunity for treating colorectal carcinoma.

Comparative study of the configuration and the cleanliness level of root canals prepared with the aid of sodium hypochlorite and bis-dequalinium-acetate solutions

Bis-dequalinium acetate (BDA), a quaternary ammonium compound, was introduced as a bactericidal and chemotherapeutic agent for endodontic use. This study was undertaken to compare the efficacy of this compound to 5.25% sodium hypochlorite in the cleansing and shaping of root canals. One hundred twenty freshly extracted teeth were divided into three groups. Each group was treated with the aid of the test material; saline solution was used as a control. After completion of the endodontic preparation, a silicone imprint of the canals was performed and the teeth were decalcified. The imprints were examined three-dimensionally to determine the amount of debris and canal configuration due to defective preparation and anatomic variation. No significant difference could be observed between the tested materials with respect to cleanliness and the shape of the canals. At the apical third, however, the BDA-treated canals showed more favorable results with respect to cleanliness. On the basis of the present and previous findings, it was concluded that BDA might be a favorable replacement for sodium hypochlorite as an irrigation solution.

The use of dequalinium acetate as a disinfectant and chemotherapeutic agent in endodontics

Dequalinium compounds are known as chemotherapeutic and bactericidal agents. They are used in various areas of medicine and oral medicine for combating cases of mixed infections. Until now, results of basic research studies have been published whose objective was to examine the suitability of dequalinium preparations as cleansing agents and intracanal dressings for endodontic use. This article presents for the first time a number of selected cases from a clinical research study in which widespread periapical lesions revealed before the start of treatment were treated with a preparation whose active ingredient was dequalinium acetate. The results of treatment and follow-up are given. These case reports show that healing of the periapical lesions occurs relatively quickly and is generally completed within a period of 9 months.

[Treatment of tonsillitis with dequalinium chloride]

44 children with acute tonsillitis were treated without the usual penicillin therapy. 22 children received lozenges containing Dequalinium chloride, 22 children received void lozenges under conditions of a double blind study. The results show that the treatment with Dequalinium chloride did not influence conditions caused by haemolytic streptococci -- verified by bacteriological examinations of pharyngeal smears -- inspite of its efficiency in vitro. Also general symptoms like fever, leukocytosis and rapid erythrocyte sedimentation rate were not influenced by Pequalinium chloride. Local symptoms like sore throat, tonsillar redness and exsudation were influenced beneficially. It can therefore be assumed that in cases of acute tonsillitis penicillin therapy is not necessary except in cases of streptococci infections. These should be excluded by pharyngeal smear. The medium of Liebermeister and Braveny is a very simple indicator to differentiate between tonsillitis caused by streptococci and tonsillitis of other origin.

[Treatment of inflammatory diseases of the mouth and throat with Larypront in ENT practice (author's transl)]

Treatment of inflammations of the oral and pharyngeal cavities (glossitis, pharyngitis, pharyngolaryngitis, tonsillitis) in 60 patients with Larypront Throat Tablets alone, without administration of systemic antibiotics, gave very good results in 49 cases (81.6%) with complete regression of the complaints in 3-4 days. In 11 patients with acute pharyngitis and tonsillitis without demonstrable effect, systemic antibiotic therapy had to be added because of radiologically demonstrable acute sinusitis or increasing antibacterial infection. Side effects were not seen with the use of Larypront in any case.