The Restoration of the Vaginal Microbiota After Treatment for Bacterial Vaginosis with Metronidazole or Probiotics

Article (PDF Available)inMicrobial Ecology 65(3) · December 2012with388 Reads
Impact Factor: 3.12 · DOI: 10.1007/s00248-012-0154-3 · Source: PubMed
Abstract
Whether or not treatment with antibiotics or probiotics for bacterial vaginosis (BV) is associated with a change in the diversity of vaginal microbiota in women was investigated. One hundred fifteen women, consisting of 30 healthy subjects, 30 BV-positive control subjects, 30 subjects with BV treated with a 7-day metronidazole regimen, and 25 subjects with BV treated with a 10-day probiotics regimen, were analyzed to determine the efficacy and disparity of diversity and richness of vaginal microbiota using 454 pyrosequencing. Follow-up visits at days 5 and 30 showed a greater BV cure rate in the probiotics-treated subjects (88.0 and 96 %, respectively) compared to the metronidazole-treated subjects (83.3 and 70 %, respectively [p = 0.625 at day 5 and p = 0.013 at day 30]). Treatment with metronidazole reduced the taxa diversity and eradicated most of the BV-associated phylotypes, while probiotics only suppressed the overgrowth and re-established vaginal homeostasis gradually and steadily. Despite significant interindividual variation, the microbiota of the actively treated groups or participants constituted a unique profile. Along with the decrease in pathogenic bacteria, such as Gardnerella, Atopobium, Prevotella, Megasphaera, Coriobacteriaceae, Lachnospiraceae, Mycoplasma, and Sneathia, a Lactobacillus-dominated vaginal microbiota was recovered. Acting as vaginal sentinels and biomarkers, the relative abundance of Lactobacillus and pathogenic bacteria determined the consistency of the BV clinical and microbiologic cure rates, as well as recurrent BV. Both 7-day intravaginal metronidazole and 10-day intravaginal probiotics have good efficacy against BV, while probiotics maintained normal vaginal microbiota longer due to effective and steady vaginal microbiota restoration, which provide new insights into BV treatment.

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HOST MICROBE INTERACTIONS
The Restoration of the Vaginal Microbiota After Treatment
for Bacterial Vaginosis with Metronidazole or Probiotics
Zongxin Ling & Xia Liu & Weiguang Chen & Yueqiu Luo & Li Yuan &
Yaxian Xia & Karen E Nelson & Shaolei Huang & Shaoen Zhang &
Yuezhu Wang & Jieli Yuan & Lanjuan Li & Charlie Xiang
Received: 11 September 2012 / Accepted: 6 December 2012
#
Springer Science+Business Media New York 2012
Abstract Whether or not treatment with antibiotics or pro-
biotics for bacterial vaginosis (BV) is associated with a change
in the diversity of vaginal microbiota in women was investi-
gated. One hundred fifteen women, consisting of 30 healthy
subjects, 30 BV-positive control subjects, 30 subjects with BV
treated with a 7-day metronidazole regimen, and 25 subjects
with BV treated with a 10-day probiotics regimen, wer e
analyzed to determine the efficacy and disparity of diversity
and richness of vaginal microbiota using 454 pyrosequencing.
Follow-up visits at days 5 and 30 showed a greater BV cure
rate in the probiotics-treated subjects (88.0 and 96 %, respec-
tively) compared to the metronidazole-treated subjects (83.3
and 70 %, respectively [p0 0.625 at day 5 and p0 0.013 at day
30]). Treatment with metronidazole reduced the taxa diversity
and eradicated most of the BV-associated phylotypes, while
probiotics only suppressed the overgrowth and re-established
vaginal homeostasis gradually and steadily. Despite signif-
icant interindividual variation, the microbiota of the actively
treated groups or participants constituted a unique profile.
Along with the decrease in pathogenic bacteria, such as
Gardnerella, Atopobium, Prevotella, Megasphaera, Corio-
bacteriaceae, Lachnospiraceae, Mycoplasma,andSneathia,
a Lactobacillus-dominated vaginal microbiota was recovered.
Acting as vaginal sentinels and biomarkers, the relative abun-
dance of Lactobacillus and pathogenic bacteria determined
the consistency of the BV clinical and microbiologic cure
Electronic supplementary material The online version of this article
(doi:10.1007/s00248-012-0154-3) contains supplementary material,
which is available to authorized users.
Zongxin Ling, Xia Liu, and Weiguang Chen contributed equally to this
work.
Clinical Trial Registration: ChiCTR-TRC-11001484 (www.chictr.org)
Z. Ling
:
W. Chen
:
Y. Luo
:
L. Yuan
:
L. Li (*)
:
C. Xiang (*)
State Key Laboratory for Diagnosis and Treatment of Infectious
Diseases, the First Affiliated Hospital, College of Medicine,
Zhejiang University, Hangzhou, Zhejiang 310003, China
e-mail: ljli@zju.edu.cn
e-mail: cxiang@zju.edu.cn
Z. Ling
e-mail: lingzongxin_lzx@163.com
W. Chen
e-mail: sheyyg@163.com
X. Liu
Department of Intensive Care Unit, the First Affiliated Hospital,
College of Medicine, Zhejiang University, Hangzhou,
Zhejiang 310003, China
e-mail: wl.114@163.com
Y. Xia
Department of Obstetrics and Gynecology, the First Affiliated
Hospital, College of Medicine, Zhejiang University, Hangzhou,
Zhejiang 310003, China
K. E. Nelson
:
C. Xiang
J. Craig Venter Institute, Rockville, MD 20850, USA
S. Huang
:
S. Zhang
:
J. Yuan (*)
Insititue of Microecology, Dalian Medical University, Dalian,
Liaoning 116044, China
e-mail: Jieli_yuan@163.com
Y. Wang
Chinese National Human Genome Center at Shanghai,
Shanghai 201203, China
Microb Ecol
DOI 10.1007/s00248-012-0154-3
Page 1
rates, as well as recurrent BV. Both 7-day intravaginal
metronidazole and 10-day intravaginal probiotics have
good efficacy against BV, while probiotics maintained
normal vaginal microbiota longer due to effective and
steady vaginal microbiota restoration, which provide new
insights into BV treatment.
Introduction
Bacterial vaginosis (BV) is the most common disorder in
women of reproductive age. BV can be microbiologically
characterized by replacement of the lactobacilli-predominant
vaginal microbiota by potential pathogenic vaginal bacteria
[1]. The change from a healthy, H
2
O
2
- and lactic acid-
producing lactobacilli-dominated microbiota to a complex
multispecies microbiota can occur relatively quickly and
result in BV [2, 3]. Our previous studies have profiled
the overall structure of vaginal communities and clearly
demonstrated that BV is associated with a dramatic increase in
the taxonomic richness and diversity of vaginal microbiota
[1, 4]. The dramatic shifts in vaginal microbiota contribute
to pH elevation and sialidase and amine production,
which eventually lead to the observed signs and symptoms
[1, 5].
The current recommended treatment of BV includes met-
ronidazole (oral or vaginal) or clindamycin (vaginal) [6, 7];
however, the short-term (30 days) cure rate is often poor and
recurrences are comm on [5, 810]. Recently, probiotic ther-
apy has been shown to be effective against BV and confers a
range of other health benefits [11, 12]. The increased dom-
inance of lactobacil li after active treatment has been shown
to be effective in assessing the normality or health of the
vaginal microbiota [5]. The diversity and richness of the
vaginal microbiota a fter shor t-te rm trea tment mi ght also
affect the long-term efficacy against BV. Fredricks et al.
used quantitative polymerase chain reaction (qPCR) assays
to assess the vaginal-predominant microbiota in BV patients
after metronidazole treatment and showed that BV-associated
bacteria decreased dramatically [15]. Of note, the details
of the overall structure of the vaginal microbiota after
treatment with metronidazole or probiotics have not been
thoroughly investigated.
In the present clinical cohort study, living preparations of
Lactobacillus delbrueckii subsp. lactis DM8909 were used
to treat women with symptomatic BV vaginally, while met-
ronidazole was used as a control. To characterize the vaginal
microbiota after treatment, we characterized the overall
structure of the vaginal microbiota using 454 pyrosequenc-
ing. These results were helpful in clarifying the efficacy of
probiotics on BV and the effects of probiotics on the diver-
sity of vaginal microbiota, thus providing new insights into
BV treatment.
Materials and Methods
Probiotics
L. delbrueckii subsp. lactis DM8909, derived from a healthy
gut, was identifie d by the Institute of Microbiology of the
Chinese Academy of Science. L. delbrueckii subsp. lactis
DM8909, which was used in the current study, does not
contain a plasmid and has been used and approved as a
probiotics by the Food and Drug Administration of China
since 2001. Each suppository contained at least 10
9
colony-forming units of live Lactobacillus, can produce
various anti-infective agents, including lactic acid and
H
2
O
2
, and is able to co-aggregate efficiently with vaginal
pathogens. It is also able to adhere to human epithelial cells at
high levels and exert colonization resistance to displace vag-
inal pathogens.
Study Population
A clinical cohort trial was conducted to compare intravagi-
nal metronidazole (500 mg once daily at bedtime for 7 days
[BV-M group]) and an intravaginal probiotic Lactobacillus
capsule (once daily at bedtime for 10 days [BV-L group]) in
the treatment of BV. One hundred ninety-one women, con-
sisting of 121 women actively treated for BV, 30 BV-
positive controls before treatment, and 40 healthy controls
(CN group) who presented to our hospital for routine gyne-
cologic examinations between July 2010 and June 2011, were
recruited in the treatment trial. Informed written consent was
obtained from all participants prior to enrollment, with ap-
proval of the Ethics Committee of the First Affiliated Hospital,
College of Medicine, Zhejiang University (Zhejiang Province,
China). Individuals who participated in this study were exam-
ined by two gynecologists. BV status was assessed using the
Amsel clinical criteria for all subjects [16] and confirmed
using Gram stain criteria (Nugent scores) [17]. The inclusion
and exclusion criteria for these patients were shown in detail
in Supplementary Information Materials and Methods as pre-
viously described [1, 18].
Therapy was initiat ed after the enrollment visit or imme-
diately after the end of menstruation if menses were
expected within a 7-day period. One hundred twenty-one
BV-positive w omen were randomized to treatment with
intravaginal metronidazole (n0 68) and intravaginal probi-
otics (n0 53, Fig. 1), while 40 healthy controls were not
treated. All participants were asked to avoid sexual inter-
course and vaginal douching during treatment. Among the
participants, 55 BV-positive women (BV-M [n0 30] and BV-
L women [n0 25]) and 30 CN women completed two men-
strual cycles and had vaginal swabs for Nugent scoring and
bacterial diversity analysis. Samples were obtained 5 and
30 days after the last treatment in the three groups, and
Z. Ling et al.
Page 2
vaginal swabs were collected from 30 BV-positive women
(BV group) during the same time period, which were used
as positive controls. The BV participants with clinical cures
were evaluated according to Amsel criteria in combination
with Nugent scores (<4). The clinical data for each partici-
pant are shown in Table S1.
Diversity and Richness of Vaginal Microbiota Analysis
When women underwent genital examinations before and
after treatment, vaginal swabs were obtained near the mid-
vagina using a sterile swab from each woman, packaged,
and placed in ice packs. BV status was assessed with the
Amsel clinical criteria and Nugent scoring system; the vag-
inal swabs used for bacterial genomic DNA extraction were
transferred to the laboratory in an ice box immediately and
stored at 80 °C after preparation within 15 min for further
analysis. One hundred fifteen samples obtained from the
first follow-up a fter treatment were used to determine the
bacterial diversity of vaginal microbiota. The methods for
total bacterial genomic DNA extraction, PCR amplification,
qPCR, 454 pyro seque ncing, and statistical analysis were
performed as described in our previous studies [1, 19] (see
Supplementary Information Materials and Methods).
Accession Numbers
The sequence data have been deposited in the GenBank
Sequence Read Archive with accession number SRP007938.
Results
Clinical Outcome
Of the 121 BV patients enrolled in the current study, 55 who
completed the two follow-up visits could be evaluated for
efficacy. Of the 55 participants, 22 of 25 patients (88.0 %)
were cured with Lactobacillus,comparedwith25of30
patients (83.3 %) who were cured with metronidazole (p0
0.625) at the first follow-up visi t based on the Amsel criteria
and Nugent scoring criteria. The Lactobacillus and metro-
nidazole treatment groups were similar with respect to over-
all clinical o utcomes. Both metronidazole and probiotics
rapidly relieved the clinical signs and symptoms of BV, such
as vaginal discomfort, elevated pH, and homogeneous mal-
odorous vaginal discharge, and the Nugent scores were <4
(Table S1). At the second follow-up visit during the next
menstrual cycle, only four women in the BV-M group and
one woman in the BV-L group had clinically persistent BV;
however, 5 of 25 clinically cured women in the BV-M group
relapsed, while no relapses occurred in the BV-L group
(p<0.05; Table 1). Our result indicated that a 10-day regimen
of Lactobacillus DM8909, administered as an intravaginal
suppository, was as effective as a 7-day regimen of vaginal
metronidazole (500 mg ) in the treatment of BV, with no
recorded relapses.
Fig. 1 Randomization and
follow-up of participants
Table 1 Summary of clinical outcome after actively treated with
metronidazole or Lactobacillus
Follow-up
visit
Clinical
status
No. (%) of patients evaluated
a
p
b
Lactobacillus
treatment
group (n0 25)
Metronidazole
treatment
group (n0 30)
1st
(5-day)
Cured 22 (88.0 %) 25 (83.3 %) 0.625
Clinical failure 3 (12.0 %) 5 (16.7 %)
2nd
(30-day)
Cured 24 (96.0 %) 21 (70.0 %) 0.013
Clinical failure 1 (4.0 %) 9 (30.0 %)
Relapsed
c
0 (0/22, 0.0 %) 5 (5/25, 20.0 %)
a
As defined by Nugent scoring
b
Based on chi-square test
c
None clinically cured cases (0/22) in the Lactobacillus treatment
group and five clinically cured cases (5/25) in t he metronidazole
treatment group relapsed in the second follow-up visit
Vaginal Microbiota Restoration
Page 3
Different Diversity of Vaginal Microbiota After Treatment
Table S2 summarizes the indices of vaginal bacterial diver-
sity based on the operational taxonomic units (OTUs) esti-
mated and clearly showed that bacterial diversity in the BV-
M group and BV-L group was much more complex than the
CN group, while less complex than the BV-positive control
group (p<0.05). O ur data also showed that the vaginal
bacterial diversity in the BV-L group was significantly dif-
ferent from women in the BV-M group (p<0.05). By
rarefaction analysis estimates, the trend for species richness
was as follows: BV-L > BV > BV-M > CN (Fig. 2a). In the
four groups, a long tail in the rank abundance curves was
observed, indicating that the majority of OTUs was present
at low abundance (Fig. 2b). The vaginal bacterial commu-
nities in each group were grouped according to community
composition using UniFrac metrics (Fig. 2c). The clustering
was complemented by an analysis of bacterial richness
using the number of shared and unique OTUs in the four
groups (Fig. 2d), indicating that a core microbiome existed
Fig. 2 Rarefaction curves were used to estimate richness (in this
case the number of taxa at a 3 % dissimilarity level) among CN, BV,
and BV treated with metronidazole and Lactobacillus groups at the
first follow-up visit (at day 5) (a). The v ertical axis shows the
number of OTUs that would be expected to be found after sampling
the number of tags or sequences shown on the horizontal axis. Rank
abundance curve of bacterial OTUs derived from four groups (b).
Differentiation in vaginal bacterial communities from CN, BV, and
BV treated with metronidazole and Lactobacillus groups at the first
follow-up visit (at day 5) and 115 individual samples. Community
differentiation was measured by using the unweighted UniFrac algo-
rithm; the scale bar indicates the distance between clusters in Uni-
Frac units. All of the branch nodes shown here were found to be
significant (p<0.001), indicating that BV, CN, and two BV-treated
groups harbored distinct bacterial communities, w hile BV-treated
groups showed significant microbiota restoration (c). Venn diagram
representation of the OTU richness shared among bacterial 16S
rRNA gene libraries from the four groups. Total observed richness
was 6,143 OTUs at 97 % similarity. Percentages reflect those OTUs
unique to that group (d)
Z. Ling et al.
Page 4
in healthy vaginas. Principal coordinates analysis (PCA)
showed that two BV actively treated samples and healthy
control samples clustered more tightly than the BV-positive
control, although several clinically persistent BV actively
treated samples clustered into the BV-positive control group
(Fig. 3c ).
Lactobacilli-Dominant Vaginal Microbiota After Treatment
The total number of unique sequences from the vagina
was 33,722, which was assigned into seven phyla, while
Actinobacteria, Bacteroidetes, Firmicutes, and Fusobacte-
ria constituted the dominant phyla (Fig. 3b). In the devel-
opment of BV, the vaginal bacterial profiles could change
quite rapidly and extensively from a profile in w hich
members of the Firmicutes, especially lactobacilli, domi-
nate to a profile with a high abundance of Bacteroidetes,
Fusobacteria, and Actinobacteria members, while reversal
of the composition of vaginal microbiota indicated the
recovery of BV after treatment (Fig. S1A). At the genus
level, sequenc es from the four groups represented 161
different genera ( Table S3). Figure 3a shows that 28
genera constituted >99 % of the vaginal microbiota, while
other rare minor genera accounted for <1 % of the vaginal
microbiota, which confirmed the rank abundanc e curve in
Fig. 2b. Specifically, the nearly equivalent change in trends in
the BV-M and BV-L women were an increase in Lactobacillus
and a decrease in Gardnerella, Atopobium, Coriobacteria-
ceae, Megasphaera, Gemella, Lachnospiraceae, Sneathia,
Prevotella, and Mycoplasma (Fig. S1B) [1]. In agreement
with the clinical outcome, the higher relative abundance
of Lactobacillus after active treatment was one of the
most important parameters for r estoration of normal
vaginal homeostasis; however, there were also dramatic
interindividual variations among these samples, especial-
ly for BV-positive controls and BV-L participants (Fig.
S2A, B). The predominant bacteria of the vaginal
microbiota in women who were clinically cured of BV
and those with clinically persistent BV following one
short-term treatment are presented in Fig. 4. The relative
abundance of predominant bacteria in the BV-M group
was more concentrated and much more dispersed in the
BV-L group. Verifying the results of pyrosequencing by
qPCR, our data showed more abundant total bacteria
and Lactobacillus crispatus su bgr oup s colonized in the
BV-L group, while Lactobacillus iners was the most predom-
inant bacteria in the BV-M group at the first follow-up visit
(Table S4).
Fig. 3 The relative abundance of vaginal bacterial V3 tags obtained
by pyrosequencing from CN, BV, and BV treated with metronida-
zole and Lactobacillus at the first follow-up visit (at day 5), by
genus (a) and by phylum (b). Phylogenetic classification for the
pyrosequencing analysis obtained from Ribosomal Database Project
Classifier analyses. PCA of vaginal bacterial communities among
four groups obtained by pyrosequencing and performed using R
program (c)
Vaginal Microbiota Restoration
Page 5
Discussion
The results of the current clinical cohort trial suggest that
metronidazole and the probiotics, L. delbrueckii subsp. lactis
DM8909, can cure BV by >80 % after short-term treatment.
Both agents can be used to treat BV. The vaginal microbiota
plays an important role in determining the efficacy of agents
for BV. With the next generation of high-throughput sequenc-
ing techniques, most of the clinically cured subjects could
restore lactobacilli-dominant vaginal microbiota and maintain
vaginal homeostasis over a relative long period. However, the
overall structure of vaginal microbiota was different after
treated with metronidazole and probiotics, including the di-
versity, composition, and richness, which might be ascribed to
the different antimicrobial mechanisms. For the first time, we
have characterized the disparity of vaginal microbiota after
BV treatment in depth.
As an antimicrobial agent, metronidazole has been used
extensively for the management and prophylaxis of anaero-
bic infections, including symptomatic BV [7 ]. Notably, the
relative abundance of lactobacilli increased with recovery,
coinciding with a decrease in the members of Actinobacte-
ria, Bacteroidetes, and Fusobacteria, indicating a tendency
for lactobacilli-dominant vaginal microbiota restoration. En-
dogenous lactobacilli, such as L. iners, become the predom-
inant bacteria of the vaginal microbiota after treatment;
however, our data indicated that metronidazole could not
re-establish healthy vaginal homeostasis after eradicating
BV-associated pathogens, as the total number of vaginal
bacteria was reduced significantly. The vulnerable vagina
could re-establish vaginal eubiosis after killing those patho-
gens thoroughly in one side and could also be easily re-
colonized by residual pathogenic microorganisms in the
other side. An equilibrium in the v aginal microbiota must
be established for a relatively long time. Patients with a
higher BV recurrence rate (16 %) shoul d be followed more
closely for residual pathogenic microorganisms. A previous
study has also highlighted the persistent problem of BV,
resorting to long-term antibiotic therapy to prevent recurren-
ces [10]. However, Bradshaw et al. reported that prolonged
metronidazole treatment does not prevent the recurrence of
BV or abnormal vaginal microbiota in the majority of
women [8]. In addition, the decrease in susceptibility to
metronidazole for those pathogenic microorganisms could
lead to final BV treatment failure, especially for the recent-
ly described metronidazole-resistant Atopobium vaginae
[20]. For those clinical persistent infections, a higher rela-
tive abundance of pathogenic bacteria, such as Gardnerella
and Atopobium, were also found in the present study. The
taxonomic distribution of these predominant bacteria in the
vagina also confirmed the relationship between the clinical
cure rate and residual pathogens, thus the higher BVrecurrence
rate in this group.
The use of L. delbrueckii subsp. lactis DM8909 for BV
treatment, like other probiotic strains, such as Lactobacillus
GR-1, RC-14, Lactobacillus casei rhamnosus, Lactobacillus
brevis,andLactobacillus plantarum, can improve urogenital
health through immune modulation, pathogen displacement,
and creation of a niche less conducive to proliferation of
pathogens and virulence factors [11, 13, 14, 21]. In addition,
L. delbrueckii subsp. lactis DM8909 could colonize in the
vagina for a relatively long time and facilitate re-establishment
of the physiologic vaginal microbiota. Other than metronida-
zole, probiotics could not eradicate most of the pathogenic
microorganisms rapidly, but only inhibit the overgrowth of
those pathogenic bacteria gradually. Thus, the diversity of
vaginal microbiota was much more complex than that of the
BV-M group. Although the relative abundance of lactobacilli
was slightly lower, the total number of lactobacilli was more
than that in metronidazole-treated group. The replenishment
of these exogenous Lactobacillus intravaginally restores vag-
inal homeostasis with different mechanisms, including
Fig. 4 Different distribution of
number reads of predominant
genera in patients with
clinically cured and clinically
persistent BV treated with
metronidazole and
Lactobacillus at the first
follow-up visit (at day 5)
Z. Ling et al.
Page 6
producing hydrogen peroxide, lactic acid, and bacteriocins,
which could suppress the overgrowth of those pathogenic
microorganisms mentioned above and encourage the recovery
of endogenous lactobacilli [2224]. A previous study has
reported that the loss of endogenous vaginal lactobacilli is
important in the acquisition of BV [25]. The recovery of
endogenous lactobacilli is one of the most important markers
or sentinels for BV cure. Indeed, the restoration of vaginal
endogenous lactobacilli is a slow process. The restoration of
endogenous lactobacilli steadily after probiotics treatment,
which confers strong colonization resistance, would replace
pathogens and re-establish vaginal homeostasis. This could
explain why women treated with probiotics have a lower
recurrence rate in the long term. For those participants with
antibiotic-resistant microorganisms and recurrences, it is nec-
essary to treat them with other antibiotics based on antimicro-
bial susceptibility profiles alone or in combination with
probiotics, or with complete replacement by probiotics. Re-
search has shown that the intravaginal use of Lactobacillus,or
antibiotics plus probiotics, yields a cure rate of approximately
88 % [11, 26]. The alternative natural treatment could be
effective in the microbiologic and clinical resolution of BV
without side effects [13, 27, 28].
There w ere several limitations to the c urrent study.
First, the present study was not a double-blind, placebo-
controlled clinical trial, which presented an opportunity
for bias of the clinical outcome after treatment. Second,
there was no long-term follow-up analysis of the vaginal
microbiota after active treatment. For such an analysis, it
would be helpful to guide the clinical treatment of BV and
evaluate its prognosis. Third, recurrent BV treatment was
not included in the present study, which might be more
useful for elucidating BV treatment failure with antibiotic
administration. Fourth, clinically persistent BV should
undergo antibiotic-resistant gene detection in the vaginal
microbiota after metronidazole treatment, which suggests
that treatment failed with the recommended therapy direct-
ly and that an alternative therapy must be chosen, such as
probiotics.
Conclusions
The present study indicated that Lactobacillus DM8909, ad-
ministered as an intravaginal suppository, is as effective as
vaginal metronidazole in the treatment of bacterial vaginosis,
with a lower relapse rate. Our results provide convincing
evidence that the overall structure of vaginal microbiota dif-
fered significantl y between women with BV treated with
metronidazole and probiotics, at least in the short term. Spe-
cifically, multiple analyses indicated that the richness was
greater in the Lactobacillus-treated group, while evenness
tended to be greater in the metronidazole-treated group.
However, despite dramatic interpersonal variations, both ac-
tively treated groups had an apparent increase in the
lactobacilli-dominant vaginal microbiota and a dramatic reduc-
tion in pathogenic microorganisms. The changing pattern of
vaginal microbiota after active treatment showed an obvious
trend of vaginal microbiota restoration and vaginal homeosta-
sis re-establishment. Along with antibiotic administration, pro-
biotics offered an alternative means to treat and prevent BVand
help to maintain a healthy vaginal ecosystem.
Acknowledgments This work was supported by the National Basic
Research Program of China (973 program) Grant 2013CB531404 and
a Qiu-Shi Scholarship from Zhejiang University. We would like to
thank all the participants recruited in this study.
Conflict of interest The authors declare no conflict of interest.
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    • "V ( Donders et al . , 2010 ; Ling et al . , 2013 ) . Further analysis of one pilot study that utilized probiotics in patients with BV revealed that probi - otics do not eliminate harmful taxonomy , as did antibiotics , but rather suppressed the overgrowth of bacterial strains associated with BV thus possibly leading to its enhanced effectiveness ( Ling et al . , 2013 ) . Additionally , it has been reported that inoculation of the uterine microbiome with Lactobacillus crispatus at the time of embryo transfer can increase implantation rates and reduce colonization of pathogenic microorganisms ( Sirota et al . , 2014 ) ."
    [Show abstract] [Hide abstract] ABSTRACT: Humans have evolved along with the millions of microorganisms that populate their bodies. These microbes (1014) outnumber human cells by 10 to 1 and account for 3 × 106 genes, more than ten times the 25,000 human genes. This microbial metagenome acts as our “other genome” and like our own genes, is unique to the individual. Recent international efforts such as the Human Microbiome Project (HMP) and the MetaHIT Project have helped catalog these microbial genomes using culture-independent, high-throughput, next-generation sequencing. This manuscript will describe recent efforts to define microbial diversity in the female reproductive tract because of the impact that microbial function has on reproductive efficiency. In this review, we will discuss current evidence that microbial communities are critical for maintaining reproductive health and how perturbations of microbial community structures can impact reproductive health from the aspect of infection, reproductive cyclicity, pregnancy, and disease states. Investigations of the human microbiome are propelling interventional strategies from treating medical populations to treating individual patients. In particular, we highlight how understanding and defining microbial community structures in different disease and physiological states have lead to the discovery of biomarkers and, more importantly, the development and implementation of microbial intervention strategies (probiotics) into modern day medicine. Finally this review will conclude with a literature summary of the effectiveness of microbial intervention strategies that have been implemented in animal and human models of disease and the potential for integrating these microbial intervention strategies into standard clinical practice.
    Full-text · Article · Mar 2015
    Braundmeier AG Braundmeier AGLenz KM Lenz KMNicholas Chia Nicholas Chia+1more author...[...]
    • "Schwebke and Desmond (32) reported 76.8% improvement in Amsel’s criteria after treatment with metronidazole. In another study, improvement rate of Amsel’s clinical criteria at five days and at one month after treatment with metronidazole was reported as 83.3% and 70%, respectively (33). In the present study, the majority of subjects in garlic and metronidazole groups had white homogenous discharge. "
    [Show abstract] [Hide abstract] ABSTRACT: Background:Bacterial vaginosis (BV) is one of the most common gynecological infections during reproductive age. Although metronidazole is one of the most effective medications recommended as the first-line treatment, it has various side effects. Because of the side effects and contraindications of some chemical medicines, using herbs has been investigated in treating BV.Objectives:The aim of this study was to compare the effect of garlic tablet (Garsin) and oral metronidazole in clinical treatment of the BV in women referred to Resalat Health Center, affiliated with Mazandaran University of Medical Sciences, in 2013.Patients and Methods:This randomized clinical trial was conducted on 120 married women aged 18 to 44 years who were diagnosed with BV by Amsel’s clinical criteria and Gram staining. Enrolled women were randomly allocated to two groups of 60 patients and were treated with either garlic tablet or oral metronidazole for seven days. Amsel’s criteria and Gram stain were assessed seven to ten days after beginning the treatment period and side effects were registered.Results:Amsel’s criteria were significantly decreased after treatment with garlic or metronidazole (70% and 48.3%, respectively; P < 0.001). Therapeutic effects of garlic on BV were similar to that of metronidazole (63.3% and 48.3%, respectively; P = 0.141). There were significant differences between the two treatment groups in terms of side effects; metronidazole was associated with more complications (P = 0.032).Conclusions:This study reveals that garlic could be a suitable alternative for metronidazole in treatment of BV in those interested in herbal medicines or those affected by side effects of metronidazole.
    Full-text · Article · Jul 2014
    • "Amplicon pyrosequencing was performed with standard 454/Roche GS-FLX Titanium protocols, where equal molar of PCR product from each sample was pooled. To pool and sort multiple samples in a single 454 GS-FLX run, we used a set of 8-bp barcodes designed according to Fierer et al. [20,21,24,56575859. The main criterion of the barcodes is that the adjoining nucleotides are different because the single nucleotide repeats are the main source of errors in pyrosequencing technology. "
    [Show abstract] [Hide abstract] ABSTRACT: Elucidating the biogeography of bacterial communities on the human body is critical for establishing healthy baselines from which to detect differences associated with disease; however, little is known about the baseline bacterial profiles from various human habitats of healthy Chinese undergraduates. Using parallel barcoded 454 pyrosequencing targeting on the 16S rRNA gene V3 region, the bacterial diversity of the nasopharynx, saliva, dominant hands, and feces were investigated from 10 healthy Chinese junior boarding undergraduates at Zhejiang University. The participants were 21–24 years of age with a body mass index (BMI) < 24 kg/m2. A total of 156,717 high-quality pyrosequencing reads were obtained for evaluating bacterial diversity, which represented 29,887 unique phylotypes. The overall taxonomic distribution of the 16S rRNA gene-based amplicons demonstrated that these 4 habitats of the human body harbored distinct microbiota and could be divided into different clusters according to anatomic site, while the established patterns of bacterial diversity followed the human body habitat (feces, hands, saliva, and nasopharynx). Although significant inter-individual variation was observed, the healthy microbiota still shared a large number of phylotypes in each habitat, but not among the four habitats, indicating that a core microbiome existed in each healthy habitat. The vast majority of sequences from these different habitats were classified into different taxonmies that became the predominant bacteria of the healthy microbiota. We first established the framework of microbial communities from four healthy human habitats of the same participants with similar living environments for the Chinese undergraduates. Our data represent an important step for determining the diversity of Chinese healthy microbiota, and can be used for more large-scale studies that focus on the interactions between healthy and diseases states for young Chinese adults in the same age range.
    Full-text · Article · Jun 2013
    Zongxin Ling Zongxin LingXia Liu Xia LiuYueqiu Luo Yueqiu Luo+1more author...[...]
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