Transcript Probiotics

Prevention of UTIs:
Role of Hormones & Probiotics
가톨릭 의대
한창희
9th Catholic Urology Symposium
Outline
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Vaginal ecosystem
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Issues in prescribing their use
Estrogen and recurrent UTI in women
What are probiotics and how do they work?
Current proposed uses and a look at some of
the evidence
9th Catholic Urology Symposium
Health vaginal ecosystem
 Dynamic Equilibrium exists between:
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Epithelium
Normal colonizing organisms (mostly Lactobacilli SPP.)
Local secretory and celluar immune factors
Vaginal pH maintained
 acidic (3.8 ~ 4.2)
 creates unfavourable environment for pathogen
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Normal Vaginal flora
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LACTOBACILLI
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Gram positive rods
Excrete hydrogen peroxide
Present in 100% of women with normal flora
Affects adherence of epithelial cells
Protect against bacterial/candidal infections
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Facultative organisms
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Diphtheriods
Coagolase negative Staphycococci
Streptococci
E. coli
Ureaplasma urealyticum
Mycoplasma hominis
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Anaerobic organisms
Present in low, non-pathogenic concentrations
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Peptostreptococus
Bacteroides
Fusobaterium
Mobiluncus
Gardnerella (40% - 60%) in normal secretions
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Normal vaginal flora; protective role
H2O2
 Estrogen; epithelial glycogen
 Lactobacilli; glycogen -> lactic acid
 Lactic acid maintains acid pH
Lactic acid
Lactobacillus
Glycogen
estrogen
 Abnormal pH (over 4.2)
 aggravating factors:
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trauma
low estrogen
menses
alkaline seminal fluid
 alters vaginal ecosystem
 causes epithelial desquamation
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UTI in women
• 1 billion each year (Reid, 2003)
• > 300 million cases annually worldwide
(Reid 2001. Am J Clin Nutr 73: S437-S443)
• Each episode: on average 6 days of symptoms
• Sequelae: pyelonephritis --> preterm birth
• Uropathogens: E. coli (approx. 70%),
Enterobacteriacae
Enterococcus faecalis,
Staphylococcus spp.
• Increasing drug resistance among uropathogens
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Female GU Tract Infections:
Disturbance of normal vaginal flora
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UTI: Escherichia coli
Gram negatives
Staphylococcus aureus
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BV: "lactobacilli deficiency syndrome"
Gardnerella vaginalis, Atopobium vaginae, anaerobes,
Mycoplasma hominis, Ureaplasma urealyticum
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Yeast vaginitis: Candida albicans
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Which are the 'right' lactobacilli?
Identification of cultured vaginal lactobacilli using tDNAPCR
Vaginal smea rs gra ded by Gram stain
Species
La ctoba cillus
La ctoba cillus
La ctoba cillus
La ctoba cillus
La ctoba cillus
La ctoba cillus
La ctoba cillus
La ctoba cillus
La ctoba cillus
La ctoba cillus
La ctoba cillus
La ctoba cillus
La ctoba cillus
La ctoba cillus
La ctoba cillus
La ctoba cillus
La ctoba cillus
crispa tus
jensenii
ga sseri
iners
vaginalis
coleohominis
reuteri
fermentum
rhamnosus
ca sei
delbrueckii
kalixensis
pontis 94%
sa liva rius
mucosa e
oris
nagelii
Normal (439)
48.3
25.3
23.5
20.5
11.6
3.4
1.4
1.1
0.9
0.9
0.7
0.2
0.2
0.2
0.0
0.0
0.0
Disturbed (68)
7.4
38.2
39.7
27.9
4.4
1.5
0.0
1.5
4.4
2.9
1.5
0.0
0.0
0.0
2.9
2.9
1.5
H2O2 production
+++
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+
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+
+
++
+
Verhelst R. et al. BMC Microbiol. 2005, 5:
61
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Risk factors for BV
 The vagina is not a steady state ecosystem.
 Menstruation  cyclic changes in the vaginal environment
 Levels of estrogen and progesterone alter,
 Changing the environment for lactobacilli by influencing
 cell surface receptor expression
 levels of glyocgen and glucose as substrate
 levels of vaginal pH
 Estrogen protective:
 BV prevalence lower in women using oral contraception
(Yen et al. 2003)
 BV lower during pregnancy (3rd trimester) (Hay et al. 1994)
 Clinical trials with estradiol  cure of BV, restoration pH, ...
(Kanne & Jenny 1991, Parent et al. 1996, Ozkinay et al.
2005)
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Risk factors for BV
 Race/ethnicity (black women at higher risk):
 In Africa: > 50% of women have BV (Paxton et al. 1998)
 L. iners instead of L. crispatus? (Anukam et al. 2005)
 genetic differences in epithelial surface molecules
--> different adherence?
 Frequency and kind of intercourse:
 new male sexual partner
 more male sexual partners
 female sexual partner
* Sexual intercourse once a week was the only risk factor
associated with loss of H2O2 producing lactobacilli. (Vallor et al. 2001)
--> BV is STD? or raise of pH?
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Sequelae of BV (and UTI)
 HSV2 infection
 HIV shedding
(Cherpes TL 2005. CID 40: 1422)
(Cu-Uvin S. 2004. CID 33: 894,
Sewankambo. 1997. Lancet 350: 546)
--> perinatal mother-child HIV-transmission
--> sexual HIV-transmission
 susceptibility for HIV-infection
 infection with CT and HPV
(da Silva CS. 2004. GOInvest. 58:
189)
 early loss after IVF
(Eckert LO. 2003. IDOG 11: 11-17)
 associated with recurrent UTI
(Hooton TM. 2001. IJAA 17: 259-
268)
 associated with PID, postpartum endometritis, ...
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Bacterial vaginosis (BV)
Number
of germs
Normal
Bacterial vaginosis
Lactobacillus
Symptoms
Gardnerella
vaginalis
Anaerobes
pH 4.0 4.5
pH 5.0 - 6.0
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Estrogens; Clinical trials
 A controlled trial of intravaginal estriol in
postmenopausal women with recurrent UTIs
Raz R, Stamm WE. N Engl J Med 1993, 329:753-756
• 93 postmenopausal women with a history of recurrent UTIs
• Randomized, double-blind, placebo-controlled trial of
topical intravaginal estriol cream
 UTI incidence; 0.5 vs. 5.9 episodes per patient-year
 Lactobacilli restoration after one month; 61% vs 0%
 Vaginal pH declined (from 5.5 to 3.8)
 Vaginal Enterobacteriaceae fell from 67 to 31% withestriol
but unchanged (from 67 to 63 %) with placebo
• prevents recurrent UTI in postmenopausal women, probably
by modifying the vaginal flora.
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Probiotics: definitions
 World Health Organization:
 “live microorganisms which when administered in
adequate amounts confer a health benefit on the host”
 A bacterial strain that:
 survives the stomach acid and bile
 adheres to intestinal lining
 grows and establishes temporary residence in the
intestines
 imparts health benefits
R Fuller. Probiotics: The Scientific Basis. London: Chapman and Halls.
1992
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Probiotics
 Lactobacillus sp.
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reuteri
casei
ramnosus
acidophilus
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infantis
lactis
longum
breve
bifidum
 Streptococcus sp.
 Bifidobacterium sp.
 Sacharomyces boulardii (non-human)
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History of Probiotics
 Pasteur (1877)
 antagonistic interaction between bacterial strains
 non-pathogenic bacteria should be used to control
pathogenic bacteria
 Metchnikoff (1907)
 lactic fermentation of milk arrested putrefaction
 consumption of fermented products would offer the same
benefit to humans
 longevity in Bulgarian peasants was due to ingestion of
“soured milks”
 1980’s Fuller establishes first definition of probiotics.
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Probiotics;
Potential Mechanisms of Action
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Inhibition of adhesion
Immunomodulation
Production of antimicrobial substances
Modification of toxins or toxin receptors
Competition for nutrients
Reduction in bacterial translocation
Anti-inflammatory signaling within the epithelium
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Probiotics: Proposed uses
 Infectious diarrhea
 Antibiotic-associated diarrhea
 IBD, IBS, and pouchitis
 Necrotizing Enterocolitis
 Bacterial vaginosis
 Recurrent UTI’s
 Atopic diseases
 Immune system enhancement
 H pylori infections
 Dental caries
 Radiation induced diarrhea
 Cardiovascular risk reduction
 Constipation
 Rheumatoid arthritis
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Probiotics: Proposed uses
Ratings: A: strong
B: good
C: fair
Rating the Evidence
Floch et al (2006)
Natural Standard (2006)
Infectious diarrhea
A
B
AntiBx-associated diarrhea
A
C
Diarrhea prevention
B
B
IBS
C
B
Atopic dermatitis/Allergy
B?
B/C
Ulcerative colitis
C
B
H pylori infection
C
A
Bacterial vaginosis
C
C
UTIs
C
Floch, et al. Recommendations for Probiotic Use. J Clin Gastro. 40(3). 2006
www.naturalstandard.com
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Probiotics: Prescribing
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Which organism to use?
Which product?
For what conditions?
What dose?
How long?
Any side effects to be aware of?
How much does it cost?
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Vaginal probiotics; Clinical trials
 Treatment of BV with lactobacilli
Hallen A, et al. Sex Transm Dis. 1992, 19:146-148.
• 60 women with BV
• double blind, placebo-controlled trial
• Immediately after completion of treatment,
 16/28 women treated with lactobacilli had normal
vaginal wet smear results
 none of the 29 women treated with placebo.
• Only 3 of the women who received the Lactobacillus
suppository were free of BV after the subsequent
menstruation.
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Vaginal probiotics; Clinical trials
 Vaccination against nonspecific BV;
Double-blind study of Gynatren
Siboulet A. Gynakol Rundsch. 1991;31(3):153-160
• 167 patients with nonspecific BV
• vaccinated with Gynatren, a Lactobacillus vaccine
• double-blind, randomized, placebo-controlled trial
• During the study period of 14 months, vaccination was
significantly better than the placebo as concerns its
therapeutical effect
• Vaccination with Gynatren is effective to prevent
recurrences of nonspecific vaginosis.
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Vaginal probiotics; Clinical trials
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An audit of Gynatren (a L. acidophilus lyophilisate) vaccination in
women with recurrent bacterial vaginosis.
Pattman RS et al. Int J STD AIDS. 1994, 5: 299
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Bacterial vaginitis: protection against infection and secretory
immunoglobulin levels in the vagina after immunization therapy
with Gynatren.
Ruttgers H. Gynecol Obstet Invest. 1988, 26: 240-9
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Effect of Lactobacillus immunotherapy on genital infections in
women (Solco Trichovac/Gynatren).
Karkut G. Geburtshilfe Frauenheilkd. 1984, 44:
311-4
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Randomized double-blind study on the prevention of reinfection
in trichomoniasis using Solco Trichovac vaccination.
Litschgi M. Gynakol Rundsch. 1982, 22: 70-3
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Vaginal synbiotics; Clinical trials
 Therapy of bacterial vaginosis (BV) using exogenouslyapplied L. acidophili and a low dose of estriol:
a placebo-controlled multicentric clinical trial.
Parent D, et al. Arzneimittelforschung. 1996, 46: 6873
• Vaginal tablets (Gynoflor) containing 50 mg of a lyophilisate
of viable, H2O2-producing L. acidophilus (>107 CFU/tablet)
and 0.03 mg estriol
• 32 non-menopausal women with BV
• 6-day therapy with 1~2 vaginal tablets daily
 cure rate 2 wks after the start of therapy; 77% vs 25%
 cure rate 4 wks after the start of therapy; 88% vs. 22%
• A significant increase in the number of lactobacilli
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Vaginal synbiotics; Clinical trials
 The effectiveness of live lactobacilli in combination
with low dose estriol (Gynoflor) to restore the vaginal
flora after treatment of vaginal infections.
Ozkinay E, et al. Brit. J. Obstetr. Gynaecol. 2005, 112: 234-40
• Randomised, placebo-controlled, double-blind clinical trial
• 360 women with vaginal infections
• Restoration therapy with live lactobacilli in combination
with low dose estriol (n = 240) or placebo (n = 120)
2~7 days after the end of the anti-infective therapy
• Follow up at 3~7 days and 4~6 weeks after the end of the
restoration therapy
• Restoration of the vaginal flora can be significantly
enhanced by the administration of live lactobacilli in
combination with low dose estriol.
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Non-Vaginal probiotics;
Clinical trials with Yoghurt
 Ecological treatment of bacterial vaginosis.
Chimura T, et al. Jpn J Antibiot. 1995, Mar;48: 432-6
• 11 women with BV: intravaginal application of 5 ml of
commercial yoghurt (pH 4.3).
• Evaluation after 3 days: vaginal discharge and bacteriology
 Significant decrease of vaginal discharge and redness
 Vaginal pH was lowered significantly.
 Overall bacteriological effects: 6 (54.5%) were eradicated,
3 were partly eradicated, 2 were replaced.
• Lactobacillus therapy was effective in both clinical and
bacteriological responses.
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Non-Vaginal probiotics;
Clinical trials with Yoghurt
 Bacterial vaginosis in pregnancy treated with yoghurt.
Neri A, et al. Acta Obstet Gyecol Scand 1993, 72: 17-22
• 32 women with BV in the first trimester of pregnancy were
treated with intravaginal application of yoghurt.
• The result was favorable.
 Ingestion of yogurt containing Lactobacillus acidophilus
as prophylaxis for candidal vaginitis.
Hilton E, et al. Ann Intern Med 1992, 116: 353-7
• Daily ingestion of 8 ounces of yogurt containing L. acidophilus
decreased both candidal colonization and infection.
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Non-Vaginal probiotics; Clinical trials
 Augmentation of antimicrobial MDZ therapy of BV with
oral probiotic L. rhamnosus GR-1 and L. reuteri RC-14:
randomized, double-blind, placebo controlled trial.
Anukam K, et al. Microbes Infect. 2006
• 125 premenopausal women with BV
• Oral MDZ (500 mg) bid for 7 d + oral L. rhamnosus GR-1 (1x109)
and L. reuteri RC-14 (1x109) or placebo bid for 30 d
 Cure rate of BV; 88% vs 40% (p < 0.001).
 Recovery of Lactobacillus sp. counts (> 105 cfu/ml) 96% vs 53%
• Use of lactobacilli and antibiotic in the eradication of BV in
black African women is efficacious.
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Non-Vaginal probiotics; Clinical trials
 Oral use of L. rhamnosus GR-1 and L. fermentum RC-14
significantly alters vaginal flora: randomized, placebocontrolled trial in 64 healthy women.
Reid G, et al. FEMS Immunol Med Microbiol. 2003, 35: 131-4
 64 healthy women
 Oral capsules of L. rhamnosus GR-1 and L. fermentum RC14
given daily for 60 days
 Restoration from asymptomatic BV microflora to a normal
lactobacilli colonized microflora; 37% vs 13% (P=0.02).
 A significant increase in vaginal lactobacilli at day 28 and 60
 A significant depletion in yeast at day 28
 A significant reduction in coliforms at day 28, 60 and 90 for
lactobacilli-treated subjects
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Non-Vaginal probiotics; Clinical trials
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In vitro testing of Lactobacillus acidophilus NCFM as a
possible probiotic for the urogenital probiotic applications.
Reid G. Int Dairy J. 2000, 10: 415-9
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Oral probiotics can resolve UTI.
Reid G. FEMS Immunol 2001, 30:49-52
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Assessment of the capacity of lactobacilli to inhibit growth of
uropathogens.
Osset J et al. JID 2001, 183: 485-91
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Probiotic feeding reduces UTI in preterm infants.
Dani C et al. Biol Neonate 2002, 82: 103-8
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Probiotics: alternative treatment in urology.
Hoesl & Altwein. Eur Urol 2005, 47: 288-96
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Vaginal probiotic products
 CTV-05: L. crispatus 108 cfu/capsule (Chrisope Tech., La & Gynelogix, Colo.)
 Fem-Dophilus: L. rhamnosus GR-1™ and L. reuteri RC-14™ (Urex Biotech)
 Florajen: L. acidophilus 2 x 1010/capsule (American Lifeline, Wisconsin)
 Gy-Na-Tren: L. acidophilus 2 x 109 cfu/capsule (Vitalis, Nederland)
 Gynoflor: L. acidophilus 107 cfu + 0.03 mg estriol/tablet (Mithra, Liège, from
Grünenthal, produced by Medinova (Zürich, S)
 Infemin: L. crispatus, L. acidophilus, L. fermentum, L. rhamnosus,
cfu/ml
all at 109
(Pierre Fabre Sante, Boulogne, France)
 Intrafresh: vaginal probiotic pessarium: PEG + L. acidophilus (BioCare, UK)
 Lacto AC: 10 species/capsule. TJCP: The Jordan Prentice Co., Fl.
 LactoFem: L. Rhamosus, L. acidophilus both at 109/capsule (Mithra, Belgium)
 Trenev Trio (Vitals, Nederland)
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Vaginal probiotics:
Rationale to develop
 Clear hypothesis about role of lactobacilli
 Clearly established protective role of lactobacilli
 Lactobacilli are predominant in the vagina.
 Application can be topical
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 reaching high inocula
 no organoleptic considerations
Easy to perform clinical trials:
 Easy sampling
 Easy re-isolation of probiotic lactobacilli
after application
Already available
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Probiotics vs antibiotics
 Antibiotics
 damage commensal microflora.
 can increase the occurrence of resistant bacteria
 can have adverse side effects
 Probiotics
 can be used in adjunction to antibiotics to restore
the commensal microflora
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Probiotics; Practical Issues
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Not FDA regulated
 Quality control is poor
 80% of preparations tested had 1% or less of the bacterial
concentration on the label
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Numerous preparations on the market
 Which strains work best?
 Do different strains work better for different diseases?
 Do combinations work better than single strains?
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May need several months of therapy to see an effect
Likely stop working after discontinued
Concentration (dose) highly variable
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Conclusions
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The use of probiotics in prevention of UTI is promising.
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Response is species specific; the success of one species
of Lactobacillus in a certain application does not imply
that all related strains of this species will be capable of
producing a comparable response.
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Carefully conducted double-blind, placebo-controlled
studies to document the individual efficacy of each
specific organism for each potential clinical application
are needed.
Should be used carefully and cautiously, and only on the
basis of strong scientific evidence.
9th Catholic Urology Symposium