Probiotics for the treatment of bacterial vaginosis (Review) Senok AC, Verstraelen H, Temmerman M, Botta GA This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2009, Issue 4 http://www.thecochranelibrary.com Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. TABLE OF CONTENTS HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.1. Comparison 1 Probiotic + Metronidazole versus placebo + Metronidazole, Outcome 1 Microbiological cure. Analysis 2.1. Comparison 2 Vaginal probiotic capsules versus metronidazole vaginal gel, Outcome 1 Microbiological cure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.2. Comparison 2 Vaginal probiotic capsules versus metronidazole vaginal gel, Outcome 2 Resolution of symptoms as reported by patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 2.3. Comparison 2 Vaginal probiotic capsules versus metronidazole vaginal gel, Outcome 3 Adverse effects. . Analysis 3.1. Comparison 3 Probiotic versus placebo (after open treatment with clindamycin ovules), Outcome 1 Microbiological cure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.2. Comparison 3 Probiotic versus placebo (after open treatment with clindamycin ovules), Outcome 2 Resolution of symptoms as reported by patient. . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 3.3. Comparison 3 Probiotic versus placebo (after open treatment with clindamycin ovules), Outcome 3 Clinical cure as reported by physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 4.1. Comparison 4 Probiotics with estriol versus placebo, Outcome 1 Microbiological cure. . . . . . . Analysis 4.2. Comparison 4 Probiotics with estriol versus placebo, Outcome 2 Clinical cure as reported by physician. APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 1 1 2 2 3 3 5 7 8 9 10 10 10 13 20 21 21 22 22 23 23 24 24 25 25 27 27 27 27 28 28 i [Intervention Review] Probiotics for the treatment of bacterial vaginosis Abiola C Senok1 , Hans Verstraelen2 , Marleen Temmerman2 , Giuseppe A Botta3 1 Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates. 2Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium. 3 Dept of Medical and Morphological Research, Section of Microbiology, School of Medicine, University of Udine, Udine, Italy Contact address: Abiola C Senok, Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates. [email protected]. Editorial group: Cochrane Sexually Transmitted Diseases Group. Publication status and date: New, published in Issue 4, 2009. Review content assessed as up-to-date: 31 December 2008. Citation: Senok AC, Verstraelen H, Temmerman M, Botta GA. Probiotics for the treatment of bacterial vaginosis. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD006289. DOI: 10.1002/14651858.CD006289.pub2. Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background The dominance of lactobacilli in healthy vaginal microbiota and its depletion in bacterial vaginosis (BV) has given rise to the concept of oral or vaginal instillation of probiotic Lactobacillus strains for the management of this condition. Objectives To ascertain the efficacy of probiotics in the treatment of BV. Search methods We searched electronic databases irrespective of publication status or language. These included: Cochrane Central Register of Controlled Trials (CENTRAL), the HIV/AIDS and STD Cochrane Review Groups’ specialized registers, the Cochrane Complementary Medicine Field’s Register of Controlled Trials, MEDLINE (1966 to 2008), EMBASE (1980 to 2007), ISI science citation index (1955 to 2007), CINAHL (Cumulative Index to Nursing & Allied Health Literature (1982 to 2007). We handsearched of specialty journals, conference proceedings and publications list on the website of the International Scientific Association of Probiotics and Prebiotics (http://www.isapp.net/default.asp). For unpublished studies or ongoing trials, we contacted authors from relevant publications, nutraceutical companies and probioticrelated scientific associations. We searched electronic databases on ongoing clinical trials. Selection criteria Randomized controlled trials using probiotics for the treatment of women of any age diagnosed with bacterial vaginosis, regardless of diagnostic method used. The probiotic preparation could be single or “cocktail” of strains, any preparation type/dosage/route of administration. Studies comparing probiotics with placebo, probiotics used in conjunction with conventional antibiotics compared with placebo or probiotics alone compared with conventional antibiotics were eligible for inclusion. Data collection and analysis We screened titles and abstracts , obtained full reports of relevant trialsand independently appraised them for eligibility. A data extraction form was used to extract data from the four included studies. For dichotomous outcomes, odds ratios (OR) and 95% confidence intervals (CI) were derived for each study using RevMan (versions 4.2 and 5). We did not perform meta-analysis due to significant differences in the probiotic preparations and trial methodologies. Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 1 Main results Analysis suggests beneficial outcome of microbiological cure with the oral metronidazole/probiotic regimen (OR 0.09 (95% CI 0.03 to 0.26)) and the probiotic/estriol preparation (OR 0.02, (95% CI 0.00 to 0.47)). For the probiotic/estriol preparation, the OR and 95% CI for physician-reported resolution of symptoms was OR 0.04 (95% CI 0.00 to 0.56). Authors’ conclusions The results do not provide sufficient evidence for or against recommending probiotics for the treatment of BV. The metronidazole/ probiotic regimen and probiotic/estriol perparation appear promising but well-designed randomized controlled trials with standardized methodologies and larger patient size are needed. PLAIN LANGUAGE SUMMARY Probiotics for the treatment of bacterial vaginosis Bacterial vaginosis (BV) is one of the most common causes of genital discomfort in women of reproductive age. This condition occurs when there is an imbalance in the population of normal vaginal micro-organism with depletion of the dominant lactobacilli and overgrowth of other types of bacteria. Treatment of this condition using recommended antibiotics is often associated with failure and high rates of recurrence. This led to the concept of replacing the depleted lactobacilli using probiotic strains as a treatment approach. This review investigated the evidence for the use of probiotic preparations either alone or in conjunction with antibiotics for the treatment of BV. The current research does not provide conclusive evidence that probiotics are superior to or enhance the effectiveness of antibiotics in the treatment of BV. In addition, there is insufficient evidence to recommend the use of probiotics either before, during or after antibiotic treatment as a means of ensuring successful treatment or reduce recurrence. Larger, well-designed randomized controlled trials with standardized methodologies are needed to confirm the benefits of probiotics in the treatment of BV. BACKGROUND 1997; Royce 1999). The prevalence of BV varies in different parts of the world and is higher in developing countries, but there is still some controversy about whether or not BV is a sexually transmitted disease in the “traditional” sense (Larsson 2005). However, current data indicate that the overall prevalence of BV is much higher among STD clinic attendees and commercial sex workers (Behets 2001; Eschenbach 1988). Bacterial vaginosis (BV) is one of the most common causes of genital discomfort in women of reproductive age. This condition occurs as a result of an imbalance in the normal vaginal microbiota and is characterized by a decrease or depletion of the Lactobacilli spp and a concomitant overgrowth of other vaginal anaerobic bacteria. The micro-organisms commonly cultured in BV include Gardnerella vaginalis, Mobiluncus spp, Mycoplasma hominis, Prevotella spp, Preptostreptococcuss spp and more recently, new molecular methods have identified Atopobium vaginae as a BVassociated microbe (Fredricks 2005; Marrazzo 2004; Verstraelen 2004). Under normal conditions, the production of lactic acid by vaginal lactobacilli, particularly by strong hydrogen peroxide (H2 O2 ) producers such as Lactobacillus crispatus and Lactobacillus jensenii, help to maintain the low vaginal pH which prevents the overgrowth of other anaerobic bacteria (Antonio 1990). Although some women with BV remain asymptomatic, as many as 50% to 60% of BV patients report symptoms such as occurrence of malodorous “fishy” vaginal discharge. The Amsel criteria for the diagnosis of BV were first described in 1983 (Amsel 1983) and a positive diagnosis is based on the presence of at least three of the following: presence of a thin, greyish homogenous discharge; vaginal pH greater than 4.5; presence of clue cells on Gram stain; positive whiff test. The underlying cause of BV is still not fully understood, but factors such as vaginal douching, black ethnicity, low socioeconomic status, use of an intra-uterine contraceptive device, and new/multiple sex partners appear to increase the risk of this perturbation in the vaginal ecosystem (Calzolari 2000; Fonck 2001; Nilsson However, there are other diagnostic scoring systems based on the number or ratio of Lactobacilli versus other bacterial morphotypes seen on Gram stained vaginal smears or wet preparations (Forsum 2005). The Nugent system (Nugent 1991) scores the number of Lactobacilli, Gardnerella, and curved bacteria (Mobiluncus) mor- Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 2 photypes per high-power field. Various studies have used the Nugent scoring system as an alternative method to the Amsel criteria and there is a close correlation between both methods due to the high sensitivity and specificity of microbial quantification of Gram stained vaginal smears (Honest 2004). New diagnostic methods using molecular techniques are now being developed and applied in various studies (Forsum 2005; Verhelst 2004; Verstraelen 2004). It is now known that BV is associated with potentially severe gynaecological and obstetric complications and sequelae. Current data suggest a causal association between BV, pelvic inflammatory disease, and tubal factor infertility (Wilson 2002). Pregnant women with BV have a higher risk of adverse outcomes such as late miscarriage, chorioamnionitis, premature rupture of membranes, preterm birth and postpartum endometritis (Marrazzo 2004). In women undergoing in vitro fertilization, BV may result in lower implantation rates and increased rates of early pregnancy loss (Eckert 2003; Verstraelen 2005). There is growing evidence of an association between BV and sexually transmitted infections, making it of grave concern, particularly in light of the HIV/AIDS epidemic. There are data indicative of a relationship between BV and increased risk of HIV transmission and acquisition (Cu-Uvin 2001; Sewankambo 1997). The presence of BV was associated with up to a six-fold increment in quantity of HIV shedding (Cu-Uvin 2001). Furthermore, there is a correlation between the absence of vaginal lactobacilli and a positive result for the carriage of Neisseria gonorrhoeae and Chlamydia trachomatis (Wiesenfeld 2003). BV has been identified as a risk factor for herpes virus type 2 infection and increased viral shedding in infected women (Cherpes 2005). Recent reports also indicate that BV may increase the risk of acquisition or reactivation of Human Papillomavirus infection, particularly high-risk HPVtypes (da Silva 2004). The displacement of the H2 O2 -producing Lactobacilli, elevated vaginal pH with the presence of bacteria that produce sialidase and mucin-degrading enzymes as seen in BV, probably combine to create a milieu conducive to the survival of these pathogens (Olmsted 2003). In light of all these adverse BV-associated conditions, adequate treatment of this condition is crucial. Current guidelines for treatment of BV stipulate the use of metronidazole or clindamycin administered orally or intravaginally (Anonymous 2002; Marrazzo 2004). Other treatment regimens that have been suggested include acidification of the vagina and the use of povidone-iodine vaginal suppositories. Up to 10% to15% of patients fail to respond to initial antimicrobial therapy, and recurrence rates over time among responders remain significant, reaching up to 80% and necessitating repeated administration of antibiotics. Such repeated antibiotic exposure increases the risk of emergence of resistant strains, alteration of microbiota, and possible persistence of BV-associated pathogens. The high recurrence rates associated with antibiotic therapy have stimulated the search for alternative treatment modalities, which could be used with or without the current regimen. The dominance of lactobacilli in healthy vaginal microbiota and its obliteration in BV has given rise to the concept of oral or vaginal instillation of probiotic Lactobacillus strains to restore the balance. Probiotics are defined as live micro-organisms which, when administered in adequate amounts, confer a beneficial health effect on the host (Senok 2005). Available evidence now indicates that certain strains of lactobacilli when administered to patients can colonize the vagina and reduce the risk of BV (Reid 2001). Studies have been carried out to assess the efficacy of single strain or cocktail of probiotics administered orally or intravaginal in the treatment of BV (Falagas 2007). In addition, the effect of probiotics in conjunction with antibiotic regimen has also been evaluated. Lactobacilli probiotics can be used over a long time without adverse effects, making them an attractive option to antibiotics, particularly in addressing the problem of high recurrence rates. While the scientific community is still trying to determine the efficacy of probiotics in the treatment of BV, women with chronic vaginal symptoms are increasingly self-utilizing alternative remedies, in particular lactobacilli replacement therapy, as an alternative to antimicrobials (Nyirjesy 1997; Trutnovsky 2001). It is therefore of essence to conduct a rigorous systematic review of available clinical trials, with a view to ascertaining the efficacy (or lack thereof ) of probiotics in the treatment of BV, and possibly to identify strategic areas for future research. OBJECTIVES To ascertain the efficacy of probiotics in the treatment of bacterial vaginosis METHODS Criteria for considering studies for this review Types of studies Randomized controlled trials using probiotics (alone or as adjuncts to conventional antibiotics). Studies using probiotic preparations containing other substances e.g. estriol will be included although a sub-analysis will be carried out for such preparations. Types of participants Women of any age diagnosed with bacterial vaginosis, regardless of diagnostic method used. No study will be excluded because of co-infection with other sexually transmitted infections. Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 3 Types of interventions Any probiotic (single or mixture “cocktail” of strains, any preparation type, any dosage regimen, any route of administration): ·used alone and compared with placebo or no treatment; ·used in conjunction with conventional antibiotics (before, during, or after antibiotic treatment) and compared with placebo or no treatment; ·used alone and compared with conventional antibiotic regimen. Types of outcome measures Primary outcome: restoration of normal lactobacilli microbiota, with eradication of BV microbiota (’microbiological cure’), using the Nugent criteria assessment completed between days 21 and 30 days post-treatment. Secondary outcomes: ·resolution of symptoms as reported by the patient; ·clinical cure as reported by the physician or investigator; ·persistence or recurrence of BV at follow up (from 30 days posttreatment); ·occurrence of adverse reactions or side effects; ·effect on BV-associated conditions. Search methods for identification of studies We performed an exhaustive search of electronic databases irrespective of publication status or language. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), HIV/AIDS & STD Cochrane Research Groups specialty registers, Cochrane Complementary Medicine Field’s Register of Controlled Trials (all quarterly searches until July 2008), MEDLINE (1966-2008), EMBASE (1980-2007), ISI science citation index (1955-2007), CINAHL (Cumulative Index to Nursing & Allied Health Literature (1982-2007) Appendix 1. We also searched the following databases: ProQuest, FIRSTConsult, Conference Papers Index, Ovid’s Dissertation Abstracts, ScienceDirect, Blackwell Synergy. We hand searched the following: i. Specialty journals including American Journal of Obstetrics and Gynecology, Clinical Microbiology and Infection, Eastern Mediterranean Health Journal, BMJ, BMC Infectious Diseases, Journal of Antimicrobial Chemotherapy, Journal of Clinical Microbiology, Antimicrobial Agents and Chemotherapy, Journal of Medical Microbiology, Journal of Bacteriology, Journal of Applied Microbiology, Infection and Immunity, Applied and Environmental Microbiology, Clinical Microbiology Reviews, Sexually Transmitted Diseases. ii. Abstracts of major conference proceedings (including the International Society of STD Research; World AIDS Conference) to identify trials that may have not been published in full iii. Cross-checking of references cited in recent reviews and published randomized controlled trials for additional studies not identified by electronic searches iv. Abstracts and publications listed on the website of the International Scientific Association of Probiotics and Prebiotics (http:// www.isapp.net/default.asp) We contacted experts in the field (particularly probiotics) identified from relevant publications by email and formal letters. We also contacted leading nutraceutical companies marketing probiotic products. We sent emails to scientific associations dedicated to probiotic research including the International Scientific Association of Probiotics and Prebiotics, Polish Society of Probiotics and International Probiotics Association. We requested that our communication be forwarded to their members. In all of these communications, we inquired about knowledge of published and unpublished studies and ongoing trials relevant to the review.We also searched electronic databases on ongoing clinical trials (www.trialscentral.org ; www.controlled-trials.com). The following key terms were used in our search: bacterial vaginosis intersected with probiotics, lactobacilli/lactobacillus, antibiotics, drug therapy, treatment, complementary, alternative The search strategy was as follows: “Bacterial *4 Vaginosis” or “Vaginitis *4 Bacterial” or “Vaginitis *4 Nonspecific” or “Bacterial *4 Vaginitides” or “Bacterial *4 Vaginitis ” or “Bacterial *4 Vaginoses” or “Vaginitides *4 Bacterial” or “Vaginoses *4 Bacterial” or “Vaginosis, Bacterial” or “colpitis *4 Bacterial” or “Vaginitis *4 Nonspecific” or (’vaginitis’/exp AND (Bacterial or bacteria or nonspecific or “nonspecific” or “non specific”)) AND “clinical trial”/exp or “randomized controlled trial”/exp or randomization/ or “single blind procedure”/exp or “double blind procedure”/ or “crossover procedure”/ or placebo/ or “randomi*ed controlled trial*” or rct or “random allocation” or “randomly allocated” or “allocated *2 random” or “random *2 allocated” OR “single blind*” or “double blind*” or placebo* or “prospective study”/ exp or “meta analysis”/exp or ((meta *2 analy*) or metaanalys*) or (systematic *3 (review* OR overview*)) Data collection and analysis Trials selection:ACS and MF, a trained research assistant, performed the searches. We also received help from the HIV/AIDS and STD Cochrane Review Groups Trials Search Co-ordinator and the Medical Librarian, College of Medicine, University of Sharjah. The titles and abstracts from the search were screened to identify those of potential relevance for the review. In cases where we could not make a decision based on the abstract, we obtained and reviewed the full text. Following this process, we identified Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 4 17 trials which were relevant to the review protocol. We designed an eligibility assessment form. ACS, HV and MF obtained the full reports of all relevant trials and independently appraised them for eligibility using this form. We resolved disagreements about trial inclusion by discussion. Excluded trials and reasons for their exclusion are listed in “Characteristics of excluded studies” table. Assessment of methodological quality: ACS, MF and HV independently assessed the methodological quality of all eligible trials. This included the assessment of random allocation, whether or not there was concealment, whether participants, clinicians and outcome assessors were blinded or not blinded and whether intention-to-treat (ITT) analysis was carried out. We also considered whether or not all outcome measures were addressed. Where information was not clearly reported, we contacted trial authors for necessary clarification. A full description of the criteria used in assessing the risk of bias is found in the Risk of Bias Table. Data Extraction: ACS and MF developed and used a data extraction form, which they used independently to extract and record information on the results of included studies. . Where there were differences HV gave an independent assessment and final resolution was achieved by discussion. Data analysis: This was carried out using the RevMan Analyses statistical package in Review Manager (version 4.2) and this was completed using Review Manager version 5. For dichotomous outcomes we derived odds ratio (OR) and 95% confidence intervals (CI) for each study. For continuous data we intended to calculate the mean differences for each study but this was not done as there were no such data. We had planned to do the following analysis as part of a full meta-analysis: test for heterogeneity using a standard Chi2 test and where appropriate combine the results for each outcome for included studies. Where there was homogeneity, the pooled RR and 95% CI was to be calculated for dichotomous outcomes using a fixed-effect model. For continuous data, we had planned to estimate the pooled weighted mean differences (WMD) and 95% CI. In the presence of heterogeneity, we planned to explore the reason for this and if none was found, to use a random-effects model. Funnel plots were to be used for assessment of publication or other reporting bias. The nature of the included studies precluded these analysis. We did not perform a meta-analysis due to significant differences in the methodologies, regimens and probiotic preparations used in the included studies. RESULTS Description of studies See: Characteristics of included studies; Characteristics of excluded studies. We identified about 350 studies from the comprehensive search and reviewed the abstracts for all. In some cases we reviewed the full text before a decision was made. We identified 17 studies for possible inclusion and we reviewed the full text version of all of them. These studies were duplicated across at least two of the databases we searched. ACS and MF independently assessed whether these identified studies fulfilled the inclusion criteria in for the review using a pre-designed form. HV acted as an independent arbiter where there was a conflict of opinion. Four studies (Anukam 2006a; Anukam 2006b; Eriksson 2005; Parent 1996) satisfied the inclusion criteria and were included in the review. The 12 excluded trials and reasons for their exclusion are listed in the “Characteristics of excluded studies” table. Details of the four included studies are described below and in the Characteristics of Included Studies Table (Characteristics of included studies) Anukam 2006a was a randomized controlled double blinded trial to assess the efficacy of augmentation of oral metronidazole with oral probiotics in the treatment of BV. In this study, over 500 subjects were screened and 125 pre-menopausal women (aged 18 to 44 years) fitting the entry criteria of having clinical features of BV, positive Nugent and BVBlue (salidase test) score were recruited. The exclusion criteria were use of antibiotics in the preceding 14 days, pregnancy, lactation, evidence of gross inflammatory genital process, presence of sexually transmitted infection, use of investigational drugs within 30 days, hypersensitivity to metronidazole, warfarin, lithium or disulfaram and menstruation at time of diagnosis. A power calculation for sample size was carried out. The patients were randomized in a double blind manner and given oral metronidazole 500 mg twice daily for seven days, plus either oral L. rhamnosus GR-1 and L. reuteri RC-14 (1x109 CFU per capsule) twice daily for 30 days starting on day one of metronidazole treatment (n = 65) or identical looking placebo capsules (n = 60). At the end of the treatment period three vaginal swabs were collected and evaluated for BV status. Of the 125 women enrolled, only 96 (84.8%) returned for follow up on day 30 (16 patients in the placebo arm and 3 patients in the treatment arm were lost to follow up).The primary outcome was cure of BV as determined by normal Nugent score, absence of clue cells, negative salidase test and no symptoms or signs of BV at day 30. Intention-to-treat analysis was not carried out. There was no occurrence of adverse effects. Anukam 2006b was a randomized double blind clinical trial in which intravaginal probiotic capsules was compared with metronidazole gel for the treatment of BV. The sample size of twenty women per treatment group was based on the expectation of finding a 50% difference between the two treatment groups. The inclusion criteria were presence of vaginal discharge, unpleasant fishy odour, with or without localized vaginal irritation / discomfort. Exclusion criteria include pregnancy, age < 18years or > 50years, menstruating at time of diagnosis or due to menstruate over the following five days, HIV positive, urogenital infections including yeast vaginitis and sexually transmitted infections. The 40 women enrolled in the study had the diagnosis of BV confirmed based on Nugent score (> 7) and positive salidase test. Twenty women were Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 5 randomized to receive probiotic intravaginal capsule containing L. rhamnosus GR-1 and L. reuteri RC-14 (1x109 CFU per capsule) nightly for five nights. The other 20 women applied 0.75% metronidazole gel twice daily intravaginally for 5 days. The women were assessed on days 0, 6, 15, and 30 at which time two vaginal swabs were collected and assessed for Nugent scoring, KOH and salidase test. There was 100% follow-up on days 6 and 15 and all women demonstrated compliance by returning empty treatment vials. Three women in the probiotic arm and 2 in the metronidaozole group failed to return for follow up on day 30. Adverse effects were not described. Eriksson 2005 assessed the efficacy of the use of vaginal lactobacilli after open treatment with vaginal clindamycin ovules. The inclusion criteria were based on the diagnosis of BV by Amsel’s criteria, age > 18 years and menstruating. The women had to be willing to use a tampon during menstruation. Subjects were excluded if they were pregnant, had used antibiotics in the week preceding the diagnosis of BV or had presence of vaginal yeast or Chlamydia trachomatis infection. A power calculation was carried out to determine sample size. During the open part of the trial all 225 enrolled subjects were treated with clindamycin ovules 100 mg inserted vaginally once daily for three days irrespective of whether they were randomized into the probiotic group or the placebo group. In the following menstruation, patients received either a lactobacilli impregnated tampon (n = 91) or placebo tampons (n = 96). They had to use at least five tampons to be included in the efficacy analysis and all unused tampons were returned. At the second menstruation, the women used their normal menstrual protection. The lactobacilli impregnated tampons contained L. casei var rhamnosus, L. gasseri and L. fermentum (1x108 per tampon). After the first menstruation (during which study tampons were used) and after the second menstruation, the patients sent self-taken vaginal smears to the study co-ordinator. At the followup after the second menstruation, the patients were re-evaluated using Amsel’s criteria and another vaginal smear was taken. The microbiological cure rates were determined after the second menstruation using Nugent score and Amsel’s criteria. Only 187 participants were included in the ’per protocol’ analysis as 30 women were lost to follow up and another 38 were excluded due to violation of protocol. Intention-to treat-analysis was carried out and adverse effects were reported. Parent 1996 evaluated the efficacy of vaginal tablets containing L. acidophilus and estriol. This was a randomized, placebo-controlled clinical trial with a parallel-group design. Thirty-two nonmenopausal women (24 pregnant and 8 pregnant) diagnosed with BV based on Amsel’s criteria were enrolled. Patients were excluded from the study if they had used topical or systemic hormonal treatment (except oral contraceptives) or had undergone any local vaginal treatment in the two weeks prior to the trial, had metrorrhagia or acute vaginitis. The participants were randomly allocated into lactobacilli and placebo groups using a pre-determined randomization scheme. The lactobacilli group received Gynoflor vaginal tablets containing L. acidophilus (10 million viable bacteria per tablet) and 0.03 mg estriol. The placebo tablets did not contain L. acidophilus or estriol. Both groups inserted one vaginal tablet nightly for six days. Two tablets were inserted nightly by pregnant patients with abundant leukorrhea and those women who started menstruating during the treatment period (in which case therapy was interrupted and resumed after menstruation). The patients were examined and smears obtained on days 15 and 28 after onset of therapy. Microbiological cure was determined using Nugent criteria. Intention-to-treat analysis was not carried out. Adverse effects were reported. Risk of bias in included studies Two review authors independently assessed the methodological quality of the included studies. Randomization in Anukam 2006a was carried out using a computer generated scheme and allocation schedule was conducted “off-site” by the pharmacy. The two groups were similar at baseline regarding the presence of BV. All assessors and patients were blinded. Measures of the key outcome was obtained from 106 women who returned for a follow-up visit. There was possible attrition bias due to patients lost to follow up and there was no statement on intention-to-treat analysis. The statistical analysis was well described and used appropriately. The results of betweengroup statistical comparisons as well as the measure of the size of the treatment effect were reported for the key outcome measure. Randomization in Anukam 2006b was carried out using a computer generated scheme and patients in both study groups were similar at baseline. Allocation concealment was carried out “offsite” by the pharmacy. The patients were not blinded, however the assessors (clinical and laboratory) were blinded. Only 87.5% of patients returned for follow up on day 30, which may have introduced some attrition bias. All subjects for whom outcome measures were available received the treatment or placebo as allocated. There was no statement on intention-to-treat analysis. The statistical analysis was well described and used appropriately. Randomization in Eriksson 2005 was carried out but the method used was not described. Allocation concealment was not carried out. Blinding of patients and clinical assessors was inadequate due to slight colour differences between the probiotic and the placebo tampons. Not all the subjects for whom outcome measures were available received the treatment or placebo as allocated. Data for those excluded for protocol violation and drop outs were adequately addressed. Intention-to-treat analysis was performed. The results of between-group statistical comparisons as well as the measure of the size of the treatment effect were reported. Randomization in Parent 1996 was carried using a “pre-determined randomization scheme”. Allocation concealment was not stated and there was no mention or description of blinding. We contacted the authors for clarification but received no reply. There was possible attrition bias due to patients lost to follow up. The Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 6 statistical analysis (per-protocol) was well described and used appropriately. The results of between-group statistical comparisons as well as the measure of the size of the treatment effect were reported for the key outcome measure. A detailed description can be found in the Risk of Bias Table. See Figure 1 and Figure 2 for methodological quality graph and summary respectively. Figure 1. Methodological quality graph: review authors’ judgements about each methodological quality item presented as percentages across all included studies. Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 7 Figure 2. Methodological quality summary: review authors’ judgements about each methodological quality item for each included study. Effects of interventions Primary outcome: All four included studies assessed microbiological cure as a key outcome measure. Using the reported data for the primary outcome, we calculated the Odds Ratio (OR) and 95% Confidence Interval (CI) for each study. Anukam 2006a reported a statistically significant difference at the day 30 follow up in the per-protocol analysis with 43 of the 49 (88%) women in the antibiotic/probiotic treatment arm having normal Nugent scores compared to 23 of the 57 women (40%) in the antibiotic/placebo arm: OR 0.09 (95% CI 0.03 to 0.26). This finding is suggestive of a beneficial effect of the antibiotic/ probiotic regimen in the treatment of BV. In Anukam 2006b, according to the per-protocol analysis, 11 of the 17 (64.7%) women in the probiotic arm had normal Nugent scores on day 30 compared to 6 out of 18 (33.3%) in the metronidazole arm: OR 0.27 (95% CI 0.07 to 1.10). In Eriksson 2005, the ITT analysis of the primary outcome published in the article was based on Amsel’s criteria. The assessment of the primary outcome based on Nugent criteria was presented only for those included in the per-protocol analysis. The study authors kindly provided us with the ITT analysis data (for 217 women) based on Nugent criteria. Of the 108 women in the treatment arm, 75 (69.4%) had normal Nugent scores at follow up after the second menstruation compared to 80 out of 109 (73.3%) in the placebo arm: OR 1.21 (95% CI 0.67 to 2.19). InParent 1996, microbiological cure on day 28 was documented in 7 of the 8 (87.5%) women in the probiotic/estriol arm compared to 1 out of 7 (14.2%) in the placebo/estriol arm: OR 0.02 (95% CI 0.00 to 0.47). This statistical analysis suggests that the probiotic/ Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 8 estriol regimen is beneficial for the treatment of BV. Secondary outcomes: Not all the studies assessed all the five secondary outcomes outlined in our review protocol. None of the studies reported on: (i) persistence or recurrence of BV at follow up from 30 days post treatment or (ii) effect on BV associated outcomes. The other three secondary outcomes, (i) resolution of symptoms as reported by the patient, (ii) clinical cure as reported by the physician or investigator and (iii) occurrence of adverse reactions or side effects were reported. We used the data from each study that reported any of these three secondary outcomes to calculate the Odds ratio (OR) and 95% Confidence Interval (CI). 1. Resolution of symptoms as reported by the patient This outcome was reported in Anukam 2006b and Eriksson 2005. In Anukam 2006b , 15 of the 17 (88.2%) women in the probiotic arm reported resolution of symptoms compared to 12 of the 18 (66.6%) women in the metronidazole arm: OR 0.27 (95% CI 0.05, 1.57). The authors of Eriksson 2005 provided us with data on the resolution of symptoms as assessed by the patient at follow up. Data for 55 women was stated as missing and the ITT analysis for 216 women showed that 74 out of 108 (68.5%) in the treatment arm reported complete resolution of symptoms compared to 67 out of 108 (62%) in the placebo arm: OR 0.75 (95% CI 0.43 to 1.32). 2. Clinical cure as reported by physician or investigator This was reported in two studies. In Eriksson 2005, clinical cure based on Amsel’s criteria was reported. The authors confirmed that these data were used as the assessment of physician-reported clinical cure. Clinical cure was reported for 64 out of 111 (57.6%) women in the treatment arm and 68 out of 113 (60.1%) in the placebo arm: OR 1.11 (95% CI 0.65 to 1.89). Parent 1996 reported clinical cure on day 28 based on Amsel criteria. In the probiotic/estriol group, 7 of the 8 (87.5%) women were reported as clinically cured compared to 2 out of 9 (22.2%) women in the placebo/estriol group: OR 0.04 (95% CI 0.00 to 0.56). The finding from Parent 1996 is suggestive of a beneficial effect with the probiotic/estriol regimen. 3. Occurrence of adverse effects or side effects Anukam 2006a reported that there were no adverse effects. In Anukam 2006b, 2 out of 17 (11.7%) women in the probiotic arm reported adverse effects versus 11 out of 18 (61.1%) women in the metronidazole group: OR 0.08 (95% CI 0.01 to 0.49) There was no significant difference in the severity, nature and frequency of adverse events between the treatment and control groups in Eriksson 2005. The most common adverse event was clinical Candida infection which occurred in 14.2% of those receiving the probiotic treatment and in 13.5% of the control. The author of Parent 1996 reported good tolerability without giving data on adverse effects. DISCUSSION BV occurs as a result of imbalance in the normal vaginal microbiota and is characterized by a decrease or depletion of the Lactobacilli spp and a concomitant overgrowth of other vaginal anaerobic bacteria. It remains a common cause of genital discomfort in women and it is associated with potentially severe gynaecological and obstetric sequelae. Unfortunately, currently available treatment of BV with the use of metronidazole or clindamycin administered orally or intravaginally has been shown to be associated with poor initial cure rates in 10% to 15% of patients and recurrence rates of up to 80% in those who show initial response. The dominance of lactobacilli in healthy vaginal microbiota and its obliteration in BV has given rise to the concept of oral or vaginal instillation of probiotic Lactobacillus strains to restore the balance. Indeed, available evidence now indicates that certain strains of lactobacilli administered intravaginally are capable of colonizing the vagina. This systematic review assesses the evidence for the use of probiotic regimen in the treatment of BV. We identified four randomized controlled trials which investigated the use of probiotics in women with BV and met the inclusion criteria outlined in the protocol for this systematic review. There were significant variations in the design of the trials identified. Anukam 2006a assessed the efficacy of augmentation of oral metronidazole with oral probiotics in the treatment of BV. In contrast, Anukam 2006b compared intravaginal probiotic capsules with metronidazole gel for the treatment of BV. Eriksson 2005 used clindamycin ovules for the open treatment followed by use of probiotic impregnated tampons versus placebo tampons. Parent 1996 used combined probiotic/estriol vaginal tablets with both pregnant and non-pregnant women included in the study population. As per our protocol, the results of included studies were to be combined for each outcome where appropriate and a metaanalysis conducted. However, due to these significant differences in the types of probiotics used and the trial methodologies, we did not perform a meta-analysis. Variation in the methodologies and probiotic preparations is thus identified as a major hindrance in comparing the outcome of different trials, making it difficult to conclude on the beneficial effect of probiotics in the treatment of BV and we recommend that this should be addressed in the design of future trials. Methodological quality was inadequate in two studies (Eriksson 2005; Parent 1996). The randomization method was not adequately described and allocation concealment was not carried out in either study. Although described as a randomized placebo-controlled clinical trial with parallel group design, there was no mention or description of blinding in Parent 1996. Although three studies (Anukam 2006a; Anukam 2006b; Eriksson 2005) did power calculations to determine sample size, in all the trials patients were lost to follow up leading to considerable possible attrition bias. It is therefore possible that the sample size of these included studies were ultimately not large enough to detect statis- Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 9 tical significant differences between the treatment groups. Nevertheless, for dichotomous outcomes, the odds ratio (OR) and 95% confidence intervals (CI) were derived for each study. This analysis of OR and CI for individual studies for the outcomes of microbiological cure was suggestive of a beneficial effect only for the augmentation of oral metronidazole with oral probiotics regimen (Anukam 2006a) and the probiotic/estriol regimen (Parent 1996). In addition, physician reported resolution also favoured the probiotic/estriol regimen (Parent 1996). However, for the resolution of symptoms as assessed by the patient, analysis of the data was not suggestive of a beneficial effect for the use of probiotics and the finding was similar irrespective of the routes of administration of the probiotic (oral, vaginal capsules or impregnated tampons), antibiotic use before/during the probiotic treatment or the type of probiotic preparation (single or cocktail, combined with estriol). In general, good tolerability and safety profiles were reported in all included studies. Analysis of OR which could only be carried for one study (Anukam 2006b) was suggestive of good tolerability: OR 0.08 (95% CI 0.01 to 0.49). However, irrespective of the findings of the derived OR and 95% CI, it must be emphasized that a meta-analysis is still required to conclusively determine the beneficial effect and safety profile of probiotics in the treatment of BV. Thus we recommend large scale, well-designed clinical trials which are standardized to address issues of differences in methodologies and probiotic preparations ensuring that strains which have been shown to colonize the vagina are used. The oral metronidazole/oral probiotic regimen appears promising, and we suggest further trials to investigate this treatment approach. The high incidence of recurrence is a major limitation associated with the use of antibiotics and should be evaluated as an important outcome if probiotics are to be considered successful for the treatment of BV. However none of the studies reported data on BV recurrence following probiotic use. In addition, as BV is associated with a number of gynaecological and obstetric complications, the effect of probiotics on such sequelae is an important secondary outcome. Unfortunately, this was not evaluated in any of the studies. AUTHORS’ CONCLUSIONS Implications for practice The results do not provide sufficient evidence for or against recommending probiotics for the treatment of BV. In addition, there is no conclusive evidence to recommend the use of probiotics either before, during or after antibiotic treatment as a means of ensuring successful treatment or reduce recurrence. Implications for research There is a need for well-designed randomized controlled trials with standardized methodologies and larger patient size. ACKNOWLEDGEMENTS We thank Dr Malaz Fadlallah who worked as a research assistant on this project for her assistance in the identification of studies and data collection. We acknowledge the assistance of Ms Nadia Masood, Librarian, College of Medicine, University of Sharjah in the development of the search strategy and carrying out the search. REFERENCES References to studies included in this review Anukam 2006a {published data only} Anukam K, Osazuwa E, Ahonkhai I, Ngwo M, Osemene G, Bruce AW, et al.Augmentation of antimicrobial metronidazole therapy of bacterial vaginosis with oral probiotic Lactobacillus rhamnosus GR1 and Lactobacillus reuteri RC14: Randomized double blind placebo controlled trial. Microbes and Infection 2006;8:1450–4. Anukam 2006b {published data only} Anukam K, Osazuwa E, Osemene GI, Ehigiagbe F, Bruce AW, Reid G. Clinical study comparing probiotic Lactobacillus GR-1 and RC-14 with metronidazole vaginal gel to treat symptomatic bacterial vaginosis. Microbes and Infection 2006;8:2772–6. Eriksson 2005 {published data only} Eriksson K, Carlsson B, Forsum U, Larsson PG. A Doubleblind treatment study of bacterial vaginosis with normal vaginal Lactobacilli after an open treatment with vaginal clindamycin ovules. Acta Dermato-venereologica 2005;85: 42–6. Parent 1996 {published data only} Parent D, Bossens M, Bayot D, Kirkpatrick C, Graf F, Wilkinson FE, Kaiser RR, et al.Therapy of Bacterial Vaginosis using exogeneously-applied Lactobacilli aciophili and a low dose of estriol : A placebo-controlled multicentric clinical trial. Arzneimitell-Forschung 1996;46:68–73. References to studies excluded from this review Della 2006 {published data only} Delia A, Morgante G, Rago G, Musacchio MC, Petraglia F, De Leo V. Effectiveness of oral administration of Lactobacillus paracasei subsp. paracasei F19 in association with vaginal suppositories of Lactobacillus acidofilus in the treatment of vaginosis and in the prevention of recurrent vaginitis. Minerva Ginecologica 2006;58:227–31. Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 10 Hallen 1992 {published data only} Hallén A, Jarstrand C, Påhlson C. Treatment of bacterial vaginosis with lactobacilli. Sexually Transmitted Diseases 1992;19:146. Larsson 2008 {published data only} Larsson P, Stray-Pedersen B, Ryttig KR, Larsen, S. Human lactobacilli as supplementation of clindamycin to patients with bacterial vaginosis reduce the recurrence rate; a 6month double-blind, randomized, placebo-controlled study. BMC Women’s Health 2008;8(3):doi:10.1186/1472–6874-8-3. Marrazzo 2006 {published data only} Marrazzo JM, Cook RL, Wiesenfeld HC, Murray PJ, Busse B, Krohn M, et al.Women’s satisfaction with an intravaginal Lactobacillus capsule for the treatment of bacterial vaginosis. Journal of Women’s Health 2006;15:1053–60. Neri 1993 {published data only} Neri A, Sabah G, Samra Z. Bacterial vaginosis in pregnancy treated with yoghurt. Acta Obstetrica et Gynecologica Scandinavica 1993;72:17–19. Ozkinay 2005 {published data only} Ozkinay E, Terek MC, Yayci M, Kaiser R, Grob P, Tuncay G. The effectiveness of live lactobacilli in combination with low dose oestriol (Gynoflor) to restore the vaginal flora after treatment of vaginal infections. BJOG: An International Journal of Obstetrics and Gynaecology 2005;112:234–40. Reid 2001a {published data only} Reid G, Beuerman D, Heinemann C, Bruce AW. Probiotic Lactobacillus dose required to restore and maintain a normal vaginal flora. FEMS Immunology and Medical Microbiology 2001;32:37–41. Reid 2001b {published data only} Reid G, Bruce AW, Fraser N, Heinemann C, Owen J, Henning B. Oral probiotics can resolve urogenital infections. FEMS Immunology and Medical Microbiology 2001;30:49–52. Reid 2003 {published data only} Reid G, Charbonneau D, Erb J, Kochanowski B, Beuerman D, Poehner R, et al.Oral use of Lactobacillus rhamnosus GR-1 and L. fermentum RC-14 significantly alters vaginal flora: randomized, placebo-controlled trial in 64 healthy women. FEMS Immunology and Medical Microbiology 2003; 35:131–4. Reid 2004 {published data only} Reid G, Burton J, Hammond JA, Bruce AW. Nucleic acid-based diagnosis of bacterial vaginosis and improved management using probiotic lactobacilli. Journal of Medicinal Food 2004;7:223–8. Ronnqvist 2006 {published data only} Rönnqvist PD, Forsgren-Brusk UB, Grahn-Håkansson EE. Lactobacilli in the female genital tract in relation to other genital microbes and vaginal pH. Acta Obstetrica et Gynecologica Scandinavica 2006;85:726–35. Shalev 1996 {published data only} Shalev E, Battino S, Weiner E, Colodner R, Keness Y. Ingestion of yogurt containing Lactobacillus acidophilus compared with pasteurized yogurt as prophylaxis for recurrent candidal vaginitis and bacterial vaginosis. Arch Fam Med 1996;5:593–6. Wewalka 2002 {published data only} Wewalka G, Stary A, Bosse B, Duerr HE, Reimer K. Efficacy of povidone-iodine vaginal suppositories in the treatment of bacterial vaginosis. Dermatology 2002;204:79–85. Additional references Amsel 1983 Amsel R, Totten PA, Spiegel CA, et al.Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. American Journal of Medicine 1983;74:14–22. Anonymous 2002 Anonymous. Sexually transmitted disease treatment guidelines: Center for Disease Control and Prevention. Morbidity and Mortality Weekly Report 2002;51(RR-6): 1–80. Antonio 1990 Antonio MA, Hawes SE, Hillier SL. The identification of vaginal Lactobacillus species and the demographic and microbiologic characteristics of women colonized by these species. Journal of Infectious Diseases 1999;180:1950–6. Behets 2001 Behets F, Andriamiadana J, Rasamilalao D, et al.Sexually transmitted infections and associated socio-demographic and behavioural factors in women seeking primary care suggest Madagascar’s vulnerability to rapid HIV spread. Tropical Medicine and International Health 2001;6:202–11. Calzolari 2000 Calzolari E, Masciangelo R, Milite V, et al.Bacterial vaginosis and contraceptive methods. International Journal of Gynaecology and Obstetrics 2000;70:341–6. Cherpes 2005 Cherpes TL, Melan MA, Kant JA, et al.Genital tract shedding of herpes simplex virus type 2 in women: effects of hormonal contraception, bacterial vaginosis, and vaginal group B Streptococcus colonization. Clinical Infectious Diseases 2005;40:1422–8. Cu-Uvin 2001 Cu-Uvin S, Hogan JW, Caliendo AM, et al.Association between bacterial vaginosis and expression of human immunodeficiency virus type 1 RNA in the female genital tract. Clinical Infectious Diseases 2001;33:894–6. da Silva 2004 da Silva CS, Adad SJ, Hazarabedian de Souza MA, et al.Increased frequency of bacterial vaginosis and Chlamydia trachomatis in pregnant women with human papillomavirus infection. Gynecologic and Obstetric Investigation 2004;58: 189–93. Eckert 2003 Eckert LO, Moore DE, Patton DL, et al.Relationship of vaginal bacteria and inflammation with conception and early pregnancy loss following in-vitro fertilization. Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 11 Infectious Diseases in Obstetrics and Gynecology 2003;11: 11–17. Eschenbach 1988 Eschenbach DA, Hillier S, Critchlow C, et al.Diagnosis and clinical manifestations of bacterial vaginosis. American Journal of Obstetrics and Gynecology 1988;158:819–28. Falagas 2007 Falagas ME, Betsi GI, Athanasiou S. Probiotics for the treatment of women with bacterial vaginosis. Clinical Microbiology and Infection 2007;13:657–64. Fonck 2001 Fonck K, Kaul R, Keli F, et al.Sexually transmitted infections and vaginal douching in a population of female sex workers in Nairobi, Kenya. Sexually Transmitted Infections 2001;77: 271–5. Forsum 2005 Forsum U, Hallen A, Larsson PG. Bacterial vaginosis--a laboratory and clinical diagnostics enigma. Acta Pathologica, Microbiologica, et Immunologica Scandinavica 2005;113: 153–61. Fredricks 2005 Fredricks DN, Marrazzo JM. Molecular methodology in determining vaginal flora in health and disease: its time has come. Curr Infect Dis Rep 2005;7:463–70. Honest 2004 Honest H, Bachmann LM, Knox EM, et al.The accuracy of various tests for bacterial vaginosis in predicting preterm birth: a systematic review. BJOG: An International Journal of Obstetrics and Gynaecology 2004;111:409–22. Larsson 2005 Larsson PG, Bergstrom M, Forsum U, et al.Bacterial vaginosis. Transmission, role in genital tract infection and pregnancy outcome: an enigma. Acta Pathologica, Microbiologica et Immunologica Scandinavica 2005;113: 233–45. Marrazzo 2004 Marrazzo JM. Evolving issues in understanding and treating bacterial vaginosis. Expert Review of Antiinfective Therapy 2004;2:913–22. Nilsson 1997 Nilsson U, Hellberg D, Shoubnikova M, et al.Sexual behavior risk factors associated with bacterial vaginosis and Chlamydia trachomatis infection. Sexually Transmitted Diseases 1997;24:241–6. Nugent 1991 Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation. Journal of Clinical Microbiology 1991;29:297–301. Nyirjesy 1997 Nyirjesy P, Weitz MV, Grody MH, et al.Over-the-counter and alternative medicines in the treatment of chronic vaginal symptoms. Obstetrics and Gynecology 1997;90:50–3. Olmsted 2003 Olmsted SS, Meyn LA, Rohan LC, et al.Glycosidase and proteinase activity of anaerobic gram-negative bacteria isolated from women with bacterial vaginosis. Sexually Transmitted Diseases 2003;30:257–61. Reid 2001 Reid G, Bruce AW, Fraser N, et al.Oral probiotics can resolve urogenital infections. FEMS Immunology and Medical Microbiology 2001;30:49–52. Royce 1999 Royce RA, Jackson TP, Thorp JM, Jr, et al.Race/ethnicity, vaginal flora patterns, and pH during pregnancy. Sexually Transmitted Diseases 1999;26:96–102. Senok 2005 Senok AC, Ismaeel AY, Botta GA. Probiotics: facts and myths. Clinical Microbiology and Infection 2005;11:958–66. Sewankambo 1997 Sewankambo N, Gray RH, Wawer MJ, et al.HIV-1 infection associated with abnormal vaginal flora morphology and bacterial vaginosis. Lancet 1997;350:546–50. Trutnovsky 2001 Trutnovsky G, Law C, Simpson JM, et al.Use of complementary therapies in a sexual health clinic setting. International Journal of STD & AIDS 2001;12:307–9. Verhelst 2004 Verhelst R, Verstraelen H, Claeys G, et al.Cloning of 16S rRNA genes amplified from normal and disturbed vaginal microflora suggests a strong association between Atopobium vaginae, Gardnerella vaginalis and bacterial vaginosis. BMC Microbiology 2004;4:16. Verstraelen 2004 Verstraelen H, Verhelst R, Claeys G, et al.Cultureindependent analysis of vaginal microflora: the unrecognized association of Atopobium vaginae with bacterial vaginosis. American Journal of Obstetrics and Gynecology 2004;191: 1130–2. Verstraelen 2005 Verstraelen H, Senok AC. Vaginal Lactobacilli, probiotics and IVF. Reproductive Biomedicine Online 2005;11:674–5. Wiesenfeld 2003 Wiesenfeld HC, Hillier SL, Krohn MA, et al.Bacterial vaginosis is a strong predictor of Neisseria gonorrhoeae and Chlamydia trachomatis infection. Clinical Infectious Diseases 2003;36:663–8. Wilson 2002 Wilson JD, Ralph SG, Rutherford AJ. Rates of bacterial vaginosis in women undergoing in vitro fertilisation for different types of infertility. BJOG: An International Journal of Obstetrics and Gynaecology 2002;109:714–7. ∗ Indicates the major publication for the study Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 12 CHARACTERISTICS OF STUDIES Characteristics of included studies [ordered by study ID] Anukam 2006a Methods Randomized double blind placebo controlled trial Patients and assessors were blinded. Drop out: 19/125 (15.2%) Participants 125 premenopausal women aged 18-44 with BV as diagnosed with Nugent criteria, BV blue test and clinical features. Participants were from Benin city, Nigeria. Exclusion criteria included pregnancy, lactation, sexually transmitted disease, use of systemic/per vagina antibiotic agent within 14 days; use of investigational drugs within the preceding 30 days. Hypersensitivity to some drugs including metronidazole; menstruation at time of diagnosis Interventions Cocktail of Probiotics used in conjunction with conventional antibiotics was compared with placebo Intervention group (n = 65) received: Oral L rhamnosus GR + L reuteri RC14 given orally for 30 days AND Metronidazole 500 mg bd for 7 days taken orally 1 hr before the probiotic capsule. Placebo group received Placebo capsule given orally for 30 days AND Metronidazole 500 mg bd for 7 days taken orally 1 hr before the placebo capsule Outcomes Microbiological cure as assessed by Nugent score absence of clue cells and negative salidase test at day 30 Resolution of symptoms and signs as reported by patient and clinician at day 30 Adverse effects Notes All outcomes were analysed Risk of bias Item Authors’ judgement Description Adequate sequence generation? Yes Computer generated scheme prepared by the pharmacy. Allocation concealment? Yes Adequate, Allocation schedule was conducted off-site by the pharmacy and the patients were allotted numbers. Identical looking probiotic and placebo capsules were prepared and distributed in numbered containers by the pharmacy. The two groups were similar at baseline regarding the presence of BV Blinding? All outcomes Yes Study was described as “double blind”. Probiotic and metronidazole capsules looked Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 13 Anukam 2006a (Continued) identical. Authors confirmed to us that both patients and assessors were blinded Incomplete outcome data addressed? All outcomes Yes 19 women (3 in placebo group and 16 in probiotic group) dropped out: Reasons included feeling well and no recurrence of symptoms.This was confirmed in several patients traced by clinical staff Free of selective reporting? Yes Measures of the key outcome was obtained from 106/125 women (85%) who returned for follow up visit. All outcome measures which the authors set out to test were described in the patients who came for follow up. All subjects for whom outcome measures were available received the treatment or placebo as allocated Free of other bias? Unclear Patients lost to follow up hence possible attrition bias. There was no statement on intention-to-treat analysis Anukam 2006b Methods Randomized controlled trial. Patients were not blinded but the outcome assessors were blinded Exclusion criteria: Presence of STI; age < 18 and > 50 years; pregnancy; ongoing menstruation or due to menstruate in the following 5 days. 5/40 lost to follow up on day 30 Participants 40 pre-menopausal women with BV as diagnosed by Nugent score, positive BV blue salidase test, pH > 4.5 and KOH test positive and clinical features. Participants were from clinics around Benin City, Nigeria Interventions Cocktail of probiotics compared with antibiotic regimen Intervention group (n = 20): L rhamnosus GR1 (1x 109 ) + L reuteri RC14 (1x109 ) given per vagina at bedtime for 5 consecutive days Comparison group (n = 20): Metronidozole 0.75% vaginal gel given bd (morning and evening per vagina) for 5 days Outcomes Microbiological cure as assessed by Nugent scoring at days 6, 15 and 30 Clinical cure as reported by patient and clinician at days 6, 15, and 30 Notes Adverse effects not reported All outcomes were analysed Risk of bias Item Authors’ judgement Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Description 14 Anukam 2006b (Continued) Adequate sequence generation? Yes Computer generated scheme and patients in both study groups were similar at baseline Allocation concealment? Yes Adequate, although allocation concealment was not indicated in the article, contact with the authors confirmed that this was carried out and the allocation schedule was conducted “off-site” by the pharmacy and the patients were allotted numbers Blinding? All outcomes No The patients were not blinded to the treatment they received as one group had probiotic capsules and the other group were given metronidazole gel. However, the assessors (clinical and laboratory) were blinded to which of the treatment arms the patients belonged to Incomplete outcome data addressed? All outcomes Yes There was 100% follow-up on days 6 & 15 and all women demonstrated compliance by returning empty treatment vials. Three women in the probiotic arm and 2 in the metronidaozole group failed to return for follow up on day 30 despite all efforts to contact them Free of selective reporting? Yes All identified outcomes were reported in those who came for follow up. All subjects for whom outcome measures were available received the treatment or placebo as allocated Free of other bias? Unclear Five out of 40 women lost to follow up on day 30, possible attrition bias, no intention to treat analysis Eriksson 2005 Methods Double blind randomized controlled trial Patient and clinician blinding was not absolute because the lactobacilli tampons had a slight difference in colour compared to the placebo tampon Drop outs: 30/255 (11.8%) women were lost to follow-up. Another 38 women were excluded from “per protocol” analysis because of protocol violations Participants 255 women with BV aged 20-53 enrolled. BV diagnosed by Nugent criteria. Participants from 13 clinics in Finland, Norway and Sweden Exclusion criteria: Pregnancy, planning pregnancy, breastfeeding, antibiotic treatment Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 15 Eriksson 2005 (Continued) in preceding week to BV diagnosis; vaginal candidiasis & genital chlamydia infection Interventions Cocktail of probiotics used in conjunction with conventional antibiotics compared with placebo. All patients were first treated with clindamycin ovules 100 mg daily per vagina for 3 days Intervention group (n = 127): Probiotic tampons containing L gasseri, L casei var rhamnosus & L fermentum (each 108 org); had to use at least 5 tampons during menstruation Placebo group (n = 128): Tampons without probiotics; had to use at least 5 tampons during menstruation Outcomes Microbiological cure as evaluated by Nugent score and Amsel criteria. Resolution of symptoms as reported by patient Primary outcome was determined by Nugent score after the menstruation during which tampons were used and also after the second menstruation Notes All outcomes analysed. Only 187 women were included in “per protocol” analysis. Thirty women were lost to follow up (15 in treatment group and 15 in placebo group). Thirtyeight women were excluded for violating protocol (21 in treatment group and 17 in placebo group). Intention-to-treat analysis was carried out. Adverse reactions reported Risk of bias Item Authors’ judgement Description Adequate sequence generation? Yes Randomization was carried and this was confirmed by the authors. As stated in the article “Patients were randomized into study groups” but the method used was not described Allocation concealment? No Not used Blinding? All outcomes No The study is described as “double blind” but there was slight colour differences between the probiotic tampons and the placebo tampons. Thus the blinding of patients and clinical assessors is inadequate and this introduces a risk of bias The results of between-group statistical comparisons as well as the measure of the size of the treatment effect were reported Incomplete outcome data addressed? All outcomes Yes Not all the subjects for whom outcome measures were available received the treatment or placebo as allocated. The authors reported that 224 (87%) out of the 255 women allocated at the start of the study returned for follow up visit. Thirty pa- Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 16 Eriksson 2005 (Continued) tients were lost to follow up, and 38 more were excluded from the “per protocol analysis” due to violation of the protocol. Data for those excluded for protocol violation and drop outs were addressed. Intentionto-treat analysis was carried out for the microbiological cure which is a key study outcome Free of selective reporting? Yes All identified outcomes were reported in those who came for follow up (including protocol violators) Free of other bias? Yes Although patients were lost to follow up, intention-to-treat analysis was carried out Parent 1996 Methods Randomized placebo controlled trial with parallel group design. Blinding of patients and clinicians is unclear as it is not mentioned in the article Drop outs: 17 out of 32 patients dropped out (53%) Participants 32 women non-menopausal; (ages 20 to 52 years) with BV as diagnosed by Amsel criteria; 24 women were pregnant and 8 were non-pregnant Conducted in 3 hospital centers in Belgium Exclusion criteria: Use of topical or systemic hormonal treatment (except oral contraceptives) in the preceding 2 weeks; Any local vaginal treatment in the preceding 2 weeks; metrorrhagia; acute vaginitis Interventions The treatment group (n = 17; 11 non-pregnant and 6 pregnant) received vaginal tablets containing L acidophilus (106 CFU) and oestriol 0.03 mg Placebo group (n = 15; 13 non-pregnant and 2 pregnant) received vaginal tablets which did not contain either probiotic or oestrol. Vaginal tabs inserted at night: once daily or twice daily for 6 days. Twice daily dosing was for pregnant women with abundant leukorrhea or those whose therapy was interrupted during menstruation and continued post-menstruation Outcomes Microbiological cure (Nugent criteria) and clinical cure were determined on days 15 and 28 post intervention Notes Adverse effects and tolerability reported. No response from the authors to our enquiries Risk of bias Item Authors’ judgement Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Description 17 Parent 1996 (Continued) Adequate sequence generation? Yes Randomization was carried and the method was described as a “pre-determined randomization scheme” Allocation concealment? No No mention or description suggestive of allocation concealment and although the authors were contacted to clarify these issues, no response was received Blinding? All outcomes Unclear The trial was described as a randomized placebo-controlled clinical trial with parallel group design. There was no mention or description of blinding in the article. We did not receive any response to our communications for verification Incomplete outcome data addressed? All outcomes No In the treatment arm, 11/17 women returned on day 15 for evaluation and 8 / 17 returned for evaluation on day 28 and hence the study was particularly prone to attrition bias. In the control group 10 out of 15 women were assessed on day 15 and only 7 were evaluated on day 28. The data for those lost to follow up were not addressed Free of selective reporting? Yes All identified outcomes were reported in those who came for follow up Free of other bias? Unclear Possible attrition bias, patients lost to follow up and no intention-to-treat analysis Characteristics of excluded studies [ordered by study ID] Study Reason for exclusion Della 2006 This study described the comparison of one type of probiotic (L. acidophilus given per vagina) vs. the same probiotic given in combination with an oral probiotic. This is not in keeping with our systematic review protocol. There was no placebo control in this study Hallen 1992 The primary outcome (microbiological cure) in this study was not assessed by Nugent criteria Larsson 2008 The microbiological cure was assessed outside of the 21-30 day post-treatment window outlined in the protocol for this review. In the first menstrual cycle, women received a 7-day course of clindamycin followed immediately by 10-day course of probiotic capsules and vaginal smears were taken after cessation of bleeding. This time frame was outside the 21-30 day post-treatment. The main outcome was reduction of recurrence and women who were Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 18 (Continued) BV positive after the first menstruation were excluded from the study. Treatment efficacy was based on cure after one month and length of time to relapse. Definition of cure was based on Hay/Ison criteria Marrazzo 2006 The research question of the paper is not consistent with the research question of the systematic review: the paper specifically addresses the acceptability of probiotic; thus the primary outcome in the paper was acceptability and patient satisfaction Neri 1993 The control group consisted of women who refused any kind of intervention and there is no mention of any per vagina placebo given to these women. Methodology for assessment of primary outcome was not Nugent scoring Ozkinay 2005 Micrological assessment of vaginal smears for number of lactobacilli, leucocytes and pathogenic micro-organisms was carried out, but not according to Nugent, and hence not in accordance with our protocol Reid 2001a The study is not a randomized controlled trial Reid 2001b Study population consisted of healthy women without bacterial vaginosis. There was no control population in the study Reid 2003 64 healthy women who were not allocated for intervention on the basis of vaginal microflora at the beginning of the trial Reid 2004 The participants were healthy women who were not allocated for intervention on the basis of diagnosis of BV at the beginning of the trial. Primary outcome was evaluated on day 56 (outside of the 21-30 day window specified in our review protocol) Ronnqvist 2006 Population studied were healthy women not women with BV Shalev 1996 The definition of the study population is unclear. It is a cross-over trial and there was no control group for comparison; no indication of whether the time-out period was sufficient. There was a huge attrition rate Wewalka 2002 Not a randomized study (authors described the study as a prospective controlled blind clinical study); The intervention was comparison of probiotic with an antiseptic (betadine povidone) which is not in keeping with the systematic review protocol. Primary outcome was assessed on days 8 and 15, well before the 21-30 day window specified in the review protocol Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 19 DATA AND ANALYSES Comparison 1. Probiotic + Metronidazole versus placebo + Metronidazole Outcome or subgroup title 1 Microbiological cure No. of studies No. of participants 1 106 Statistical method Odds Ratio (M-H, Fixed, 95% CI) Effect size 0.09 [0.03, 0.26] Comparison 2. Vaginal probiotic capsules versus metronidazole vaginal gel Outcome or subgroup title 1 Microbiological cure 2 Resolution of symptoms as reported by patient 3 Adverse effects No. of studies No. of participants 1 1 35 35 Odds Ratio (M-H, Fixed, 95% CI) Odds Ratio (M-H, Fixed, 95% CI) 0.27 [0.07, 1.10] 0.27 [0.05, 1.57] 1 35 Odds Ratio (M-H, Fixed, 95% CI) 0.08 [0.01, 0.49] Statistical method Effect size Comparison 3. Probiotic versus placebo (after open treatment with clindamycin ovules) Outcome or subgroup title 1 Microbiological cure 2 Resolution of symptoms as reported by patient 3 Clinical cure as reported by physician No. of studies No. of participants 1 1 217 216 Odds Ratio (M-H, Fixed, 95% CI) Odds Ratio (M-H, Fixed, 95% CI) 1.21 [0.67, 2.19] 0.75 [0.43, 1.32] 1 224 Odds Ratio (M-H, Fixed, 95% CI) 1.11 [0.65, 1.89] Statistical method Effect size Comparison 4. Probiotics with estriol versus placebo Outcome or subgroup title 1 Microbiological cure 2 Clinical cure as reported by physician No. of studies No. of participants 1 1 15 17 Statistical method Odds Ratio (M-H, Fixed, 95% CI) Odds Ratio (M-H, Fixed, 95% CI) Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Effect size 0.02 [0.00, 0.47] 0.04 [0.00, 0.56] 20 Analysis 1.1. Comparison 1 Probiotic + Metronidazole versus placebo + Metronidazole, Outcome 1 Microbiological cure. Review: Probiotics for the treatment of bacterial vaginosis Comparison: 1 Probiotic + Metronidazole versus placebo + Metronidazole Outcome: 1 Microbiological cure Study or subgroup Treatment Control Odds Ratio n/N n/N M-H,Fixed,95% CI Weight Odds Ratio Anukam 2006a 6/49 34/57 100.0 % 0.09 [ 0.03, 0.26 ] Total (95% CI) 49 57 100.0 % 0.09 [ 0.03, 0.26 ] M-H,Fixed,95% CI Total events: 6 (Treatment), 34 (Control) Heterogeneity: not applicable Test for overall effect: Z = 4.60 (P < 0.00001) Test for subgroup differences: Not applicable 0.01 0.1 1 Favours experimental 10 100 Favours control Analysis 2.1. Comparison 2 Vaginal probiotic capsules versus metronidazole vaginal gel, Outcome 1 Microbiological cure. Review: Probiotics for the treatment of bacterial vaginosis Comparison: 2 Vaginal probiotic capsules versus metronidazole vaginal gel Outcome: 1 Microbiological cure Study or subgroup Probiotics Metronidazole gel Odds Ratio n/N n/N M-H,Fixed,95% CI Weight Odds Ratio Anukam 2006b 6/17 12/18 100.0 % 0.27 [ 0.07, 1.10 ] Total (95% CI) 17 18 100.0 % 0.27 [ 0.07, 1.10 ] M-H,Fixed,95% CI Total events: 6 (Probiotics), 12 (Metronidazole gel) Heterogeneity: not applicable Test for overall effect: Z = 1.82 (P = 0.068) Test for subgroup differences: Not applicable 0.01 0.1 Favours experimental 1 10 100 Favours control Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 21 Analysis 2.2. Comparison 2 Vaginal probiotic capsules versus metronidazole vaginal gel, Outcome 2 Resolution of symptoms as reported by patient. Review: Probiotics for the treatment of bacterial vaginosis Comparison: 2 Vaginal probiotic capsules versus metronidazole vaginal gel Outcome: 2 Resolution of symptoms as reported by patient Study or subgroup Probiotics Metronidazole gel Odds Ratio n/N n/N M-H,Fixed,95% CI Weight Odds Ratio Anukam 2006b 2/17 6/18 100.0 % 0.27 [ 0.05, 1.57 ] Total (95% CI) 17 18 100.0 % 0.27 [ 0.05, 1.57 ] M-H,Fixed,95% CI Total events: 2 (Probiotics), 6 (Metronidazole gel) Heterogeneity: not applicable Test for overall effect: Z = 1.46 (P = 0.14) Test for subgroup differences: Not applicable 0.01 0.1 1 Favours experimental 10 100 Favours control Analysis 2.3. Comparison 2 Vaginal probiotic capsules versus metronidazole vaginal gel, Outcome 3 Adverse effects. Review: Probiotics for the treatment of bacterial vaginosis Comparison: 2 Vaginal probiotic capsules versus metronidazole vaginal gel Outcome: 3 Adverse effects Study or subgroup Probiotics Metronidazole gel Odds Ratio n/N n/N M-H,Fixed,95% CI Weight Odds Ratio Anukam 2006b 2/17 11/18 100.0 % 0.08 [ 0.01, 0.49 ] Total (95% CI) 17 18 100.0 % 0.08 [ 0.01, 0.49 ] M-H,Fixed,95% CI Total events: 2 (Probiotics), 11 (Metronidazole gel) Heterogeneity: not applicable Test for overall effect: Z = 2.76 (P = 0.0058) Test for subgroup differences: Not applicable 0.01 0.1 Favours experimental 1 10 100 Favours control Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 22 Analysis 3.1. Comparison 3 Probiotic versus placebo (after open treatment with clindamycin ovules), Outcome 1 Microbiological cure. Review: Probiotics for the treatment of bacterial vaginosis Comparison: 3 Probiotic versus placebo (after open treatment with clindamycin ovules) Outcome: 1 Microbiological cure Study or subgroup Eriksson 2005 Total (95% CI) Treatment Control Odds Ratio n/N n/N M-H,Fixed,95% CI Weight Odds Ratio 33/108 29/109 100.0 % 1.21 [ 0.67, 2.19 ] 108 109 100.0 % 1.21 [ 0.67, 2.19 ] M-H,Fixed,95% CI Total events: 33 (Treatment), 29 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.64 (P = 0.52) Test for subgroup differences: Not applicable 0.01 0.1 1 Favours experimental 10 100 Favours control Analysis 3.2. Comparison 3 Probiotic versus placebo (after open treatment with clindamycin ovules), Outcome 2 Resolution of symptoms as reported by patient. Review: Probiotics for the treatment of bacterial vaginosis Comparison: 3 Probiotic versus placebo (after open treatment with clindamycin ovules) Outcome: 2 Resolution of symptoms as reported by patient Study or subgroup Eriksson 2005 Total (95% CI) Treatment Control Odds Ratio n/N n/N M-H,Fixed,95% CI Weight Odds Ratio 34/108 41/108 100.0 % 0.75 [ 0.43, 1.32 ] 108 108 100.0 % 0.75 [ 0.43, 1.32 ] M-H,Fixed,95% CI Total events: 34 (Treatment), 41 (Control) Heterogeneity: not applicable Test for overall effect: Z = 1.00 (P = 0.32) Test for subgroup differences: Not applicable 0.01 0.1 Favours experimental 1 10 100 Favours control Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 23 Analysis 3.3. Comparison 3 Probiotic versus placebo (after open treatment with clindamycin ovules), Outcome 3 Clinical cure as reported by physician. Review: Probiotics for the treatment of bacterial vaginosis Comparison: 3 Probiotic versus placebo (after open treatment with clindamycin ovules) Outcome: 3 Clinical cure as reported by physician Study or subgroup Treatment Control Odds Ratio n/N n/N M-H,Fixed,95% CI 47/111 45/113 100.0 % 1.11 [ 0.65, 1.89 ] 111 113 100.0 % 1.11 [ 0.65, 1.89 ] Eriksson 2005 Total (95% CI) Weight Odds Ratio M-H,Fixed,95% CI Total events: 47 (Treatment), 45 (Control) Heterogeneity: not applicable Test for overall effect: Z = 0.38 (P = 0.70) Test for subgroup differences: Not applicable 0.01 0.1 1 Favours experimental 10 100 Favours control Analysis 4.1. Comparison 4 Probiotics with estriol versus placebo, Outcome 1 Microbiological cure. Review: Probiotics for the treatment of bacterial vaginosis Comparison: 4 Probiotics with estriol versus placebo Outcome: 1 Microbiological cure Study or subgroup Parent 1996 Treatment Control Odds Ratio n/N n/N M-H,Fixed,95% CI 1/8 6/7 100.0 % 0.02 [ 0.00, 0.47 ] 8 7 100.0 % 0.02 [ 0.00, 0.47 ] Total (95% CI) Weight Odds Ratio M-H,Fixed,95% CI Total events: 1 (Treatment), 6 (Control) Heterogeneity: not applicable Test for overall effect: Z = 2.46 (P = 0.014) Test for subgroup differences: Not applicable 0.01 0.1 Favours experimental 1 10 100 Favours control Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 24 Analysis 4.2. Comparison 4 Probiotics with estriol versus placebo, Outcome 2 Clinical cure as reported by physician. Review: Probiotics for the treatment of bacterial vaginosis Comparison: 4 Probiotics with estriol versus placebo Outcome: 2 Clinical cure as reported by physician Study or subgroup Treatment Control Odds Ratio n/N n/N M-H,Fixed,95% CI 1/8 7/9 100.0 % 0.04 [ 0.00, 0.56 ] 8 9 100.0 % 0.04 [ 0.00, 0.56 ] Parent 1996 Total (95% CI) Weight Odds Ratio M-H,Fixed,95% CI Total events: 1 (Treatment), 7 (Control) Heterogeneity: not applicable Test for overall effect: Z = 2.39 (P = 0.017) Test for subgroup differences: Not applicable 0.01 0.1 Favours experimental 1 10 100 Favours control APPENDICES Appendix 1. Cochrane “Bacterial *4 Vaginosis” or “Vaginitis *4 Bacterial” or “Vaginitis *4 Nonspecific” or “Bacterial *4 Vaginitides” or “Bacterial *4 Vaginitis ” or “Bacterial *4 Vaginoses” or “Vaginitides *4 Bacterial” or “Vaginoses *4 Bacterial” or “Vaginosis, Bacterial” or “colpitis *4 Bacterial” or “Vaginitis *4 Nonspecific” or (’vaginitis’/exp AND (Bacterial or bacteria or nonspecific or “non-specific” or “non specific”)) AND “clinical trial”/exp or “randomized controlled trial”/exp or randomization/ or “single blind procedure”/exp or “double blind procedure”/ or “crossover procedure”/ or placebo/ or “randomi*ed controlled trial*” or rct or “random allocation” or “randomly allocated” or “allocated *2 random” or “random *2 allocated” OR “single blind*” or “double blind*” or placebo* or “prospective study”/exp or “meta analysis”/exp or ((meta *2 analy*) or metaanalys*) or (systematic *3 (review* OR overview*)) Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 25 Appendix 2. Medline (1966-2008) 1. bacterial vaginosis.mp. or exp Vaginosis, Bacterial/ 2. bacterial vaginitis.mp. or exp Vaginosis, Bacterial/ 3. exp Metronidazole/ or exp Vaginitis/ or exp Vagina/ or non*specific vaginitis.mp. or exp Sexually Transmitted Diseases/ or exp Gardnerella vaginalis/ or Vaginosis, Bacterial/ 4. bacterial vaginoses.mp. or exp Vaginosis, Bacterial/ 5. 1 or 2 or 3 or 4 6. exp Lactobacillus/ or exp Probiotics/ 7. Lactobacillus helveticus/ or lactobacilli.mp. or Lactobacillus casei/ or Lactobacillus leichmannii/ or Lactobacillus reuteri/ or Lactobacillus brevis/ or Lactobacillus plantarum/ or Lactobacillus delbrueckii/ or Lactobacillus rhamnosus/ or Lactobacillus fermentum/ 8. Lactobacillus helveticus/ or lactobacillus.mp. or Lactobacillus casei/ or Lactobacillus leichmannii/ or Lactobacillus reuteri/ or Lactobacillus brevis/ or Lactobacillus plantarum/ or Lactobacillus acidophilus/ or Lactobacillus/ or Lactobacillus rhamnosus/ or Lactobacillus fermentum/ 9. antibiotics.mp. 10. drug therapy.mp. or Drug Therapy/ 11. complementary.mp. or exp Complementary Therapies/ 12. alternative.mp. 13. treatment.mp. 14. 6 or 7 or 8 15. 9 or 10 or 11 or 12 16. 5 AND 14 AND 15 Appendix 3. EMBASE (1980-2007) 1. “Bacterial Vaginosis” 2. “Vaginitis Bacterial” 3. “Vaginitis Nonspecific” 4. “Bacterial Vaginitides” 5. “Bacterial Vaginitis ” 6. “Bacterial Vaginoses” 7. “Vaginitides Bacterial” 8. “Vaginoses Bacterial” 9. Vaginosis, Bacterial 10. colpitis Bacterial 11. “Vaginitis Nonspecific” (’vaginitis’ and (Bacterial or bacteria or nonspecific or “non-specific” or “non specific”))) 12. or / #1-11 13. Lactobacill* tw 14. exp Lactobacillus helveticus/ or lactobacillus.mp. or exp Lactobacillus casei/ or exp Lactobacillus leichmannii/ or exp Lactobacillus reuteri/ or exp Lactobacillus brevis/ or exp Lactobacillus plantarum/ or exp Lactobacillus delbrueckii/ or exp Lactobacillus acidophilus/ or exp Lactobacillus/ or exp Lactobacillus rhamnosus/ or exp Lactobacillus fermentum/ 15. #13 or #14 16. “clinical trial” or “randomized controlled trial”.mp. 17. randomization/ or “single blind procedure”.mp. 18. “double blind procedure”/ or “crossover procedure”/ or placebo/ or “randomised controlled trial”.mp. 19. rct.mp. or “random allocation”.mp. 20. “randomly allocated”.mp. 21. “allocated random”.mp. 22. “random allocated”.mp. 23. “single blind”.mp. 24. “double blind*”.mp. 25. placebo.mp. Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 26 26. 27. 28. 29. 30. “prospective study”.mp. “meta analysis”.mp. “systematic review”.mp. or / #16-28 #12 AND #15 AND #29 Appendix 4. CINAHL (1982-2007) bacter* vagin*or non*specific vagin* or vagin* AND probiotic* or lactobacill* Appendix 5. ISI science citation index (1955-2007) probiotic$ and bacter$ and vagin$ HISTORY Protocol first published: Issue 4, 2006 Review first published: Issue 4, 2009 CONTRIBUTIONS OF AUTHORS ACS formulated the idea for the review. ACS and HV developed the protocol, carried out data collection and analysis and wrote the review. MT and GAB contributed in the development of the protocol and writing the review. DECLARATIONS OF INTEREST The authors declare that they do not have any conflict of interest. SOURCES OF SUPPORT Internal sources • University of Sharjah, United Arab Emirates. Financial funding from University Research Board (URB Grant #060907) Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 27 External sources • No sources of support supplied DIFFERENCES BETWEEN PROTOCOL AND REVIEW The review has been carried out according to the criteria outlined in the protocol. As an improvement we widened the search to include more electronic databases in addition to those listed in the protocol. INDEX TERMS Medical Subject Headings (MeSH) ∗ Lactobacillus; Anti-Bacterial Agents [administration & dosage]; Clindamycin [administration & dosage]; Estriol [administration & dosage]; Probiotics [∗ administration & dosage]; Randomized Controlled Trials as Topic; Vagina [microbiology]; Vaginosis, Bacterial [microbiology; ∗ therapy] MeSH check words Female; Humans Probiotics for the treatment of bacterial vaginosis (Review) Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 28
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