Characterisation and selection of a Lactobacillus species to re-colonise the vagina of women with recurrent bacterial vaginosis

This paper reports the results of characterising and selecting a strain of Lactobacillus for potential use as a probiotic in regenerating the vaginal flora of women with recurrent episodes of bacterial vaginosis (BV). BV is a condition characterised by a depletion of vaginal lactobacilli accompanied by an overgrowth of a mixed vaginal flora of aerobic, anaerobic and micro-aerophilic species in very large numbers. BV has been associated with various gynaecological and obstetric complications and has an extremely high recurrence rate, due in part to the failure to establish a normal vaginal flora after antimicrobial therapy. A total of 60 vaginal isolates of lactobacilli was assessed for characteristics considered important for vaginal re-colonisation. The characteristics studied were the in-vitro inhibitory activity of the lactobacilli against bacterial species isolated from women with recurrent BV, acid production after growth of the lactobacilli in liquid culture, production of hydrogen peroxide (H2O2) and adhesiveness of the lactobacilli to exfoliated vaginal epithelial cells (VEC). Four strains of lactobacilli, L. acidophilus (61701 and 61880), L. crispatus (55730) and L. delbrueckii subsp. delbrueckii (65407), demonstrated the greatest inhibitory activity against the BV-associated bacterial species. Two of these isolates (55730 and 61880) produced H2O2. All four isolates produced a highly acidic environment after growth in liquid medium (pH <4). Only one of these (strain 61701) was strongly adherent to VEC (>100 bacteria/VEC). A further isolate (L. acidophilus 48101) did not demonstrate maximum inhibitory activity against BV-associated bacteria, but was found to be a strong producer of H2O2 and was also highly adherent to VEC. Isolates 61701 and 48101 could be candidates for use as probiotics for vaginal re-colonisation.     

Production and characterization of monoclonal antibodies to Mobiluncus species.

Members of the genus Mobiluncus are anaerobic motile curved rods which are associated with bacterial vaginosis (BV). Murine monoclonal antibodies (MAbs) to the ATCC type strains of M. curtisii subsp. curtisii, M. curtisii subsp. holmesii, and M. mulieris were produced and characterized by enzyme-linked immunosorbent assay and indirect immunofluorescence assay. Four MAbs were subspecies specific and reacted with M. curtisii subsp. curtisii but not with M. curtisii subsp. holmesii; four were specific for M. mulieris. The remaining antibodies demonstrated some cross-reactivity: three were species specific and reacted with both subspecies of M. curtisii, and one defined an epitope shared by M. curtisii subsp. holmesii and M. mulieris but not by M. curtisii subsp. curtisii. None of the MAbs reacted with a panel of other bacteria commonly present in the vaginas of normal women or women with BV. Examination of the molecular specificities of the antibodies by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and immunoblotting revealed four antibodies which were specific for an 82,000-dalton molecule of M. curtisii subsp. curtisii and five antibodies which bound a major band of M. mulieris at 93,000 daltons. Selected MAbs reacted in the indirect immunofluorescence assay with 24 of 25 Mobiluncus spp. clinical isolates from local women with BV and could be used for direct detection of Mobiluncus spp. in vaginal fluid from a patient with BV.     

Bacterial vaginosis.

Bacterial vaginosis (BV) is the most common of the vaginitides affecting women of reproductive age. It appears to be due to an alteration in the vaginal ecology by which Lactobacillus spp., the predominant organisms in the healthy vagina, are replaced by a mixed flora including Prevotella bivia, Prevotella disiens, Porphyromonas spp., Mobiluncus spp., and Peptostreptococcus spp. All of these organisms except Mobiluncus spp. are also members of the endogenous vaginal flora. While evidence from treatment trials does not support the notion that BV is sexually transmitted, recent studies have shown an increased risk associated with multiple sexual partners. It has also been suggested that the pathogenesis of BV may be similar to that of urinary tract infections, with the rectum serving as a reservoir for some BV-associated flora. The organisms associated with BV have also been recognized as agents of female upper genital tract infection, including pelvic inflammatory disease, and the syndrome BV has been associated with adverse outcome of pregnancy, including premature rupture of membranes, chorioamnionitis, and fetal loss; postpartum endometritis; cuff cellulitis; and urinary tract infections. The mechanisms by which the BV-associated flora causes the signs of BV are not well understood, but a role for H2O2-producing Lactobacillus spp. in protecting against colonization by catalase-negative anaerobic bacteria has been recognized. These and other aspects of BV are reviewed.     

Evaluation of liquid culture media to support growth of Mobiluncus species

Mobiluncus curtisii and M. mulieris are anaerobic, gram-negative, motile curved rods isolated commonly from the vagina of women with bacterial vaginosis. Hitherto, there has been difficulty in isolating and growing these bacteria and little attention has been paid to growth in liquid media. Reasons for establishing the means of attaining optimal growth in such media include production of antigens for diagnostic and immunological studies and production of the soluble cytotoxin. In this study the efficacy of 12 liquid culture media in supporting growth was examined. M. mulieris (strain A198) multiplied > or =10-fold in only five media - Schaedler broth, Columbia blood broth (CBB), peptone-starch-dextrose (PSD) broth, brain-heart infusion plus arginine and spent tissue-culture medium. Similarly, M. curtisii (strain A98) multiplied > or =10-fold in only three media -Schaedler broth, CBB and PSD. Some strains of both bacterial species grew very poorly or not at all, in all the media tested. With an inoculum of > or =10(5)/ml, CBB, or PSD plus 10% horse serum, supported the growth of some strains of both bacterial species to 10(9) organisms/ml within 48 h, and viable bacteria persisted longer in some media (e.g., CBB) than in others. While variation in growth of Mobiluncus spp. may occur between one laboratory and another, these observations provide the basis for optimisation of a universal liquid culture medium that should facilitate production of antigens and cytotoxin.     

Optimization of media for detection of hydrogen peroxide production by Lactobacillus species

A healthy vaginal ecosystem has been shown to be protective against the acquisition of human immunodeficiency virus and gonorrhea, and women who are colonized with H(2)O(2)-producing lactobacilli are more likely to maintain a normal vaginal flora than women with lactobacilli that do not produce H(2)O(2). The purpose of this study was to formulate a testing medium that better supports the growth and detection of H(2)O(2) by a broader range of lactobacilli than a published, widely used agar formulation (TMB). The new medium (TMB-Plus) consists of brucella agar base, 3,3',5,5'-tetramethylbenzidine, horseradish peroxidase, starch, vitamin K, hemin, magnesium sulfate, manganese sulfate, and horse serum. To validate the new formula, 256 vaginal isolates and ATCC strains were inoculated onto TMB-Plus and, for comparison, onto TMB. Growth was enhanced for 69% of the isolates on TMB-Plus, and 48% had enhanced color production. The percentage of H(2)O(2)-positive isolates increased from 71% on TMB to 79% on TMB-Plus. Formulations using Rogosa or MRS agar base in combination with peroxidase and a chromogen did not support the growth of all of the strains of Lactobacillus, and fewer H(2)O(2)-producing strains were detected on these formulations than on TMB-Plus. This new medium better supports the growth of a wider range of Lactobacillus strains isolated from the vagina and enhances the color production of H(2)O(2)-producing strains.     

Identification and H(2)O(2) production of vaginal lactobacilli from pregnant women at high risk of preterm birth and relation with outcome

Lactobacilli, principally the strains that are hydrogen peroxide (H(2)O(2)) producing, may have a protective effect against vaginal colonization by pathogenic species such as those that cause bacterial vaginosis. Previous reports have also suggested that H(2)O(2)-producing lactobacilli in the vagina may protect pregnant women against ascending infection of the chorioamniotic membranes and uterine cavity. We report the identification and H(2)O(2) production of lactobacilli isolated from vaginal swabs collected at 20 weeks' gestation from a population of pregnant women at high risk of preterm birth. We also report the correlation between identification and H(2)O(2) production in relation to the outcomes of chorioamnionitis and preterm birth. Lactobacilli were identified by partial 16S rRNA gene sequencing. H(2)O(2) production by isolates was determined by a semiquantitative method. The most commonly isolated species were L. crispatus, L. gasseri, L. vaginalis and L. jensenii. Amounts of H(2)O(2) produced by lactobacilli varied widely. The presence of lactobacilli producing high levels of H(2)O(2) in the vagina of this population of pregnant women was associated with a reduced risk of bacterial vaginosis at 20 weeks' gestation and subsequent chorioamnionitis. L. jensenii and L. vaginalis produced the highest levels of H(2)O(2). We postulate that H(2)O(2)-producing lactobacilli are able to reduce the incidence of ascending infections of the uterus and the subsequent production of proinflammatory molecules which are important in the pathogenesis of chorioamnionitis and preterm birth.     

Mobiluncus species in bacterial vaginosis: aspects of pathogenesis

Mobiluncus is an anaerobic motile rod associated with bacterial vaginosis. In this work, luminol-enhanced chemiluminescence was used to study the ability of Mobiluncus spp. from the vaginas of women with bacterial vaginosis to induce, in the presence of normal adult serum, oxidative metabolism of polymorphonuclear leukocytes, which is an indirect measure of phagocytic activity. M. curtisii induced a significantly (p less than 0.05) lower response than M. mulieris, which indicates that M. curtisii escapes phagocytosis more easily. Indirect immunofluorescence assays showed IgG antibodies to M. curtisii at significantly (p less than 0.01) higher titres than to M. mulieris in women with bacterial vaginosis. The titres were higher in patients with bacterial vaginosis than in women without vaginosis and healthy men. No antibodies to Mobiluncus spp. of secretory IgA type were found in vaginal washings. These results indicate that M. curtisii is a more virulent species than M. mulieris, and agree with reports of M. curtisii found in postoperative and extragenital infections.     

Bacterial vaginosis--a microbiological and immunological enigma

The development of bacterial vaginosis (BV) among women of childbearing age and the resulting quantitative and qualitative shift from normally occurring lactobacilli in the vagina to a mixture of mainly anaerobic bacteria is a microbiological and immunological enigma that so far has precluded the formulation of a unifying generally accepted theory on the aetiology and clinical course of BV. This critical review highlights some of the more important aspects of BV research that could help in formulating new basic ideas respecting the biology of BV, not least the importance of the interleukin mediators of local inflammatory responses and the bacterial shift from the normally occurring lactobacilli species: L. crispatus, L. gasseri, L. jensenii, and L. iners to a mixed flora dominated by anaerobic bacteria.     

Probiotics for the treatment of women with bacterial vaginosis

This review considers whether probiotics are effective agents for the treatment and/or prevention of bacterial vaginosis (BV). There seems to be an association between the absence of, or low concentrations of, vaginal lactobacilli and the development of BV. Many studies have suggested that the presence of H2O2-producing vaginal lactobacilli may protect against BV, although some studies do not support this hypothesis. In-vitro studies have suggested that certain specific strains of lactobacilli are able to inhibit the adherence of Gardnerella vaginalis to the vaginal epithelium and/or produce H2O2, lactic acid and/or bacteriocins, which inhibit the growth of bacteria causing BV. Clinical trials showed that intra-vaginal administration of Lactobacillus acidophilus for 6-12 days, or oral administration of L. acidophilus or Lactobacillus rhamnosus GR-1 and Lactobacillus fermentum RC-14 for 2 months, resulted in the cure of BV (defined as a 0-1 positive score according to Amsel's criteria), and/or reduced the recurrences of BV, and/or caused an increase in vaginal lactobacilli and restoration of a normal vaginal microbiota, significantly more frequently than did a placebo, acetic acid or no treatment. However, several trials have found no significant difference in the cure rate of BV and in the number of vaginal lactobacilli after intra-vaginal instillation of lactobacilli when compared with the effect of a placebo or oestrogen. Thus, although the available results concerning the effectiveness of the administration of lactobacilli for the treatment of BV are mostly positive, it cannot yet be concluded definitively that probiotics are useful for this purpose.     

Detection and identification of Mobiluncus species by direct filter hybridization with an oligonucleotide probe complementary to rRNA.

A hybridization assay for direct detection and identification of Mobiluncus species has been developed and tested. A [32P]-labelled synthetic oligonucleotide probe, complementary to a nucleotide sequence in the variable region V8 of Mobiluncus 16S ribosomal RNA, was utilized. One of the advantages of using rRNA as target molecule for the hybridization assays is the copy number of rRNA, which can be as high as 10(4), and that additionally three to six sites on the minus strand of the DNA gene can be utilized. This probe was found to be sensitive and to react with 62 of 68 tested typical or atypical Mobiluncus isolates. It was also specific, and was shown not to react with 96 tested unrelated bacterial species and isolates, including taxonomically closely related species like Actinomyces or Bifidobacterium spp., or with bacteria isolated from the vagina of both healthy persons with an undisturbed flora, as well as from patients suffering from the bacterial vaginosis syndrome (BV).     

Inhibition of chemotaxis by organic acids from anaerobes may prevent a purulent response in bacterial vaginosis

It has been postulated that certain organic acids produced by the anaerobes associated with bacterial vaginosis (BV) could prevent a purulent response in this infection. Varying concentrations of pure succinic, acetic and lactic acids were incubated in vitro with a monocytic cell line (MonoMac 6). High inhibition of chemotaxis was produced by succinic acid; lower inhibition and no inhibition was shown by acetic acid and lactic acid respectively. Succinic and acetic acids were detected in high concentrations in the vaginal fluid of women with BV and in culture supernates of Prevotella and Mobiluncus spp.; these acids impaired chemotaxis of MonoMac 6 cells in vitro. The vaginal fluids of normal women and the culture supernates of Lactobacillus spp. had no effect on chemotaxis.     

Microecology, bacterial vaginosis and probiotics: perspectives for bacteriotherapy

Probiotics enriched in lactobacilli have been proposed as an effective and alternative tool to antibiotics for the treatment of bacterial vaginosis. The protective role of H(2)O(2)-producing lactobacilli has been strongly emphasized, but no clear-cut correlation appears to link the metabolic characteristics of administered lactobacilli with the clinical impact of probiotic therapy. On account of our review of basic mechanisms involved in bacterial vaginosis, we suggest that lactobacilli with an elevated arginine deiminase activity could have a greater therapeutic potential than strains producing only H(2)O(2). Preliminary results from our laboratory have demonstrated that treatment with probiotics containing arginine deiminase-positive lactobacilli improves clinical symptoms and is paralleled by a significant decline of polyamine levels in vaginal microenvironment. This is of outstanding interest due to the central role of polyamines in the pathogenesis of bacterial vaginosis. We should critically rethink, against this perspective, the use of probiotics for the treatment of affected women.     

Incidence of motile, curved anaerobic rods (Mobiluncus species) in vaginal secretions

Aerobic and anaerobic cultures as well as a Gram stain and wet mount preparation were made of vaginal swabs taken from various groups of women including those with vaginal discharge. The bacteria commonly found in cultures were lactobacilli, coryneforms, Staphylococcus epidermidis and facultative streptococci. Anaerobes were isolated from 75% (475 of 632) of specimens. The incidence of Trichomonas vaginalis, Candida species, Gardnerella vaginalis and Mobiluncus species in the five groups of women varied from 2.2-5.1%, 11.5-35.7%, 23.3-36.7% and 20.0-34.8% respectively. Except for Candida species, differences in the prevalence of these organisms between the groups of women were not significant. The isolation rates of Candida species in women attending the antenatal clinic and staff health clinic were significantly higher than women in the other groups. Mobiluncus species were found to occur either with T. vaginalis, Candida species or G. vaginalis alone or with any two or with all three or in the absence of these organisms. However, the incidence of Mobiluncus species was significantly higher in women colonized with G. vaginalis (112 of 185, or 60.5%) compared with women not infected (47 of 477, or 9.8%). Also, Mobiluncus species occurred in large numbers when found in the presence of G. vaginalis. When found without G. vaginalis, Mobiluncus species occurred in much smaller numbers. As with G. vaginalis, Mobiluncus species also occurred concomitantly with certain anaerobes, mainly Bacteroides species and peptostreptococci.     

Bacterial vaginosis and vaginal microorganisms in idiopathic premature labor and association with pregnancy outcome.

The vaginal microflora of 49 women in idiopathic preterm labor was compared with that of 38 term controls to determine whether the presence of bacterial vaginosis (BV) and/or specific microorganisms would influence the rate of preterm delivery. Demographic factors, pregnancy outcome, and reproductive history were also studied. BV, as defined by the presence of clue cells in a vaginal wet mount and characteristic microbial findings in a stained vaginal smear and vaginal culture, was more common in women with preterm labor and delivery than in controls (P < 0.01). The condition, diagnosed in 41% of women who had both preterm labor and delivery (n = 22) and in 11% each of women who had preterm labor but term delivery (n = 27) and controls, was associated with a 2.1-fold risk (95% confidence intervals, 1.2 to 3.7) for preterm birth prior to 37 weeks of gestation. BV was associated with low birth weight. Of 49 women with preterm labor, 67% (8 of 12) of women with BV were delivered of low-birth-weight neonates (< 2,500 g) compared with 22% (8 of 37) of women without the condition (P < 0.0005). The presence of hydrogen peroxide-producing facultative Lactobacillus spp. was strongly negatively associated with both preterm delivery and BV. BV-associated microorganisms, i.e., Mobiluncus, Prevotella, and Peptostreptococcus species, Porphyromonas asaccharolytica, Fusobacterium nucleatum, Mycoplasma hominis, and high numbers of Gardnerella vaginalis were significantly associated with preterm delivery; all species also strongly associated with BV (P = 0.0001 for each comparison). Mobiluncus curtisii and Fusobacterium nucleatum were recovered exclusively from women with preterm delivery. Our study clearly indicates that BV and its associated organisms are correlated with idiopathic premature delivery.     

Prevalence of hydrogen peroxide-producing Lactobacillus species in normal women and women with bacterial vaginosis

A predominance of Lactobacillus species in the vaginal flora is considered normal. In women with bacterial vaginosis, the prevalence and concentrations of intravaginal Gardnerella vaginalis and anaerobes are increased, whereas the prevalence of intravaginal Lactobacillus species is decreased. Because some lactobacilli are known to produce hydrogen peroxide (H2O2), which can be toxic to organisms that produce little or no H2O2-scavenging enzymes (e.g., catalase), we postulated that an absence of H2O2-producing Lactobacillus species could allow an overgrowth of catalase-negative organisms, such as those found among women with bacterial vaginosis. In this study, H2O2-producing facultative Lactobacillus species were found in the vaginas of 27 (96%) of 28 normal women and 4 (6%) of 67 women with bacterial vaginosis (P less than 0.001). Anaerobic Lactobacillus species (which do not produce hydrogen peroxide) were isolated from 24 (36%) of 67 women with bacterial vaginosis and 1 (4%) of 28 normal women (P less than 0.001). The production of H2O2 by Lactobacillus species may represent a nonspecific antimicrobial defense mechanism of the normal vaginal ecosystem.     

DNA fingerprinting of Lactobacillus crispatus strain CTV-05 by repetitive element sequence-based PCR analysis in a pilot study of vaginal colonization

Lactobacillus crispatus is one of the predominant hydrogen peroxide (H(2)O(2))-producing species found in the vagina and is under development as a probiotic for the treatment of bacterial vaginosis. In this study, we assessed whether DNA fingerprinting by repetitive element sequence-based PCR (rep-PCR) can be used to distinguish the capsule strain of L. crispatus (CTV-05) from other endogenous strains as well as other species of vaginal lactobacilli. Vaginal and rectal lactobacilli were identified to the species level by using whole-chromosome probe DNA hybridization. The DNAs from L. crispatus, L. jensenii, L. gasseri, and an as-yet-unnamed H(2)O(2)-negative Lactobacillus species designated 1086V were subjected to rep-PCR. The results of gel electrophoresis and ethidium bromide staining of the DNA fingerprints obtained were compared. L. crispatus CTV-05 had a unique DNA fingerprint compared to all other lactobacilli. DNA fingerprints for 27 production lots of L. crispatus sampled from 1994 through 2001 were identical to that of the original strain isolated in 1993, suggesting strain stability. In a pilot study of nine women, this DNA fingerprinting method distinguished CTV-05 from other endogenous vaginal lactobacilli prior to and after vaginal capsule use. rep-PCR DNA fingerprinting is useful for strain typing and for evaluating longitudinal loss or acquisition of vaginal lactobacilli used as probiotics.     

Reservoir of four organisms associated with bacterial vaginosis suggests lack of sexual transmission.

This study consisted of a search for the possible reservoir and mode of spread of the four bacterial vaginosis-associated organisms Mobiluncus mulieris, Mobiluncus curtisii, Mycoplasma hominis, and Gardnerella vaginalis. Their occurrence in rectal, oral, and pharyngeal specimens from women with and without bacterial vaginosis, their male sexual consorts, four homosexual men, and children (altogether, 374 people) was studied. Genital samples were also obtained from all adults. All four organisms were isolated from the rectums of 45 to 62% of women with bacterial vaginosis and 10 to 14% of women without bacterial vaginosis. They also occurred in the rectums of males and children. M. hominis was recovered from the oropharynxes of 12 adults whose sexual consorts had genital occurrences of the organism. Mobiluncus spp. occurred only in the vaginas of women with bacterial vaginosis (97%). The organisms were only infrequently recovered from genital samples from 135 males. Organisms were recovered from the urethras and/or coronal sulci of 10 of 44 male consorts of women with bacterial vaginosis. However, after 2 weeks of condom use during sexual intercourse, only M. hominis remained in the urethra of one man. These findings suggest that the organisms associated with bacterial vaginosis are not spread sexually but colonize the vagina from an endogenous intestinal tract site. The pathophysiological mechanisms leading to bacterial vaginosis in a subpopulation of all women are still unknown.     

Diversity of Mobiluncus strains as demonstrated by their electrophoretic protein patterns.

The analysis of electrophoretic protein profiles of 21 Mobiluncus curtisii, 11 Mobiluncus mulieris and 3 reference strains (Mobiluncus curtisii subsp. curtisii ATCC 35241, Mobiluncus curtisii subsp. holmesii ATCC 35242 and Mobiluncus mulieris BV 64-5) demonstrated species-related patterns. A highly variable region appeared at 70-85 kDa for Mobiluncus curtisii and at 75-95 kDa for Mobiluncus mulieris, which was likely to correspond to cell surface located proteins. When performed under standardized conditions, PAGE-protein analysis allowed to define intraspecies clusters, from which some strains appeared identical. Thus, the method seemed to provide a useful additive to identify a strain at the species level and might be of epidemiological interest.     

Vaginal retention of locally administered clindamycin

Since bacterial vaginosis (BV) is characterized by a lack of, or very few, lactobacilli and high numbers of small, mostly anaerobic bacteria, an obvious treatment modality would be eradication of the BV-associated bacterial flora followed by reintroduction of lactobacilli vaginally. As probiotic treatment with lactobacilli is one tool for improving the cure rate when treating BV, it is necessary to know the length of time after treatment that clindamycin can be found in the vagina and if this could interfere with the growth of the probiotic lactobacilli. We evaluated the vaginal concentration of clindamycin in 12 women for 8 days to obtain data on the concentration of clindamycin in the vagina after intravaginal treatment with the drug. The participants were examined five times between two menstrual periods: before treatment, the day after treatment was finished, and 3, 5 and 8 days post-treatment. The first day post-treatment clindamycin 0.46 × 10(-3) to 8.4 × 10(-3) g/g vaginal fluid (median 2.87 × 10(-3)) was found. Thereafter, the concentration of clindamycin decreased rapidly. In 10 patients clindamycin was found after 3 days. A very low concentration was still present 5 days after treatment in four patients. After 8 days no clindamycin was found. Clindamycin is rapidly eliminated from the vagina, within 3-8 days, after local administration. Our results indicate that treatment with probiotic lactobacilli could be problematic if carried out within 5 days after cessation of clindamycin treatment.     

Nitrocellulose filter blots for species identification of Mobiluncus curtisii and Mobiluncus mulieris

Seventy strains of Mobiluncus, motile curved anaerobic bacteria associated with bacterial vaginosis, were correctly identified to species level by using bacteria fixed to nitrocellulose and hybridized with 32P-labeled DNA.