PROTOCOL

Rajiv Gandhi University of Health Sciences, Karnataka,

Bangalore

“COMPARATIVE ASSESSMENT OF ORAL AND LOCAL PROBIOTICS AS AN ADJUNCT TO STANDARD THERAPY FOR VULVO VAGINITIS ”

Name of the Candidate : Dr. PRAVEEN KUMAR B

Guide : Dr. PRINCY LOUIS PALATTY

CO- GUIDE : Dr. PREMA D CUNHA

Course and Subject : M.D. PHARMACOLOGY

Department Of Pharmacology,

Father Muller Medical College,

Kankanady,

Mangalore – 575 002.

2013

Rajiv Gandhi University of Health Sciences, Karnataka,

Bangalore.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. / Name of the Candidate and Address (in block letters) / DR.PRAVEEN KUMAR B
POST GRADUATE RESIDENT
DEPARTMENT OF PHARMACOLOGY
FATHER MULLER MEDICAL COLLEGE. KANKANADY
MANGALORE-575002
2. / Name of the Institution / FATHER MULLER MEDICAL COLLEGE.
KANKANADY,
MANGALORE – 575002
3. / Course of the Study and
Subject / M.D. PHARMACOLOGY
4. / Date of Admission to Course / 30.07.2013
5. / Title of the Topic:
“COMPARATIVE ASSESSMENT OF ORAL AND LOCAL PROBIOTICS AS AN ADJUNCT TO STANDARD THERAPY FOR VULVO VAGINITIS”.
6. / Brief resume of the intended work:
6.1 Need for the study:
Urogenital infections globally affects an estimated 1000000000 people annually.1 Vaginitis may either be bacterial vaginosis (BV), vulvovaginal candidiasis (VVC) or non specific including trichomoniasis etc. Polymicrobial vaginitis is not uncommon.
It is estimated that 1 in 3 women will develop BV at some point in their lives. Patients suffering from BV, have an increased risk for preterm labour, acquisition of STD and many implications on health and hygiene.1 The microorganisms incriminated in BV are very diverse, including Gardnerella vaginalis, Mobiluncus, Bacteroides, and Mycoplasma. Metronidazole or clindamycin either orally or vaginally is employed to treat BV. However, there is a high rate of recurrence. The usual medical regimen for treatment of BV is the Metronidazole 500mg twice a day for 7 days. A single 2g dose is no longer recommended by the CDC because of its low efficacy. Alternatively, tinidazole may be applied topically.
Vulvo vaginal candidiasis is very common, and estimated that about 75% of women will experience VVC at least once in their lifetime, often 15% of these turn to Recurrent VVC (RVVC). VVC is most commonly caused by Candida albicans(85%), and remaining by other strains, such as Candida glabrata, Candida krusei, Candida parapsilosis, and Candida tropicalis.3 The CDC recommended regimens 2006, any Intravaginal agents: butoconazole, clotrimazole, miconazole, nystatin, tioconazole, terconazole or Oral: fluconazole as a single dose. Non-albican Candida are commonly found in complicated cases of vaginal thrush such that first line treatment is ineffective.
Trichomonas vaginalis was originally considered a commensal until 1950, then its role as a sexually transmitted infection (STI) began to be known. Trichomoniasis has been associated with vaginitis, cervicitis, urethritis, PID and other adverse birth outcomes.7 Many other causes like bacterial, viral, chemical, poor hygiene etc can also cause VV. Trichomaniasis with other causes are considered as Non Specific causes in our study.
Standard regimine of syndromic management followed in our institute is a kit containing tab. azithromycin 1g, secnidazole 1g 2 tabs, flucanozole 150mg stat orally, followed by tablet clotrimazole 200mg+tinidazole 500mg, intra vaginal, 1 hs for 7 days.
The VV has a negative impact on womans personal confidence esteem by causing psychosexual problems like dysparenunia , sense of shame, unworthiness in informing either doctor and the partner.3 Negligence about recurrent infections leading to high morbidity, health care cost, irrational use of drugs and development of drug resistance have aroused the need for further studies in this field. Hence there is need for development of alternative strategies to prevent recurrence of resistant infections, which are cost effective, with minimal adverse effects. Probiotics are claimed to be useful in vaginitis, Thus optimizing therapy for use of probiotics as an adjunct to standard therapy in VV and formulating guidance for best route of administration, with assessment of safety efficacy profiles of the regimens, is the focus of our dissertation.
2. Review of literature:
Vulvovaginitis is most common in women of all age group. Its mainly because of disturbance in the normal microbial flora in the vagina and colonization by disease causing bacteria, altering the local condition and creating unfavorable environment for normal floras existance. Probiotics defined as living micro organisms which when administered in adequate amounts confer a health benefit to host by promoting colonization of normal flora and reduce infection, prevent recurrence of infection for longer time.4 Probiotics - Lactobacillus are most common dominant microorganism in the vagina of premenopausal women, they produce lactic acid and other substances, which maintain a low pH in the vagina, preventing overgrowth of pathogens in bacterial vaginosis ,candidiasis, and other non h2o2 producing lactobacilli infections.6 In 2009 one Cochrane review did not find probiotics useful in the treatment of BV while another concluded they were effective when combined with antibiotics. Other studies have found probiotics to be highly effective (88–90% cure rate at 1 month) either alone or in combination with antibiotics, either taken orally or applied topically (vaginally), and significantly superior to antibiotics alone.4 Some studies have also found probiotics useful in maintenance therapy, preventing recurrence. One Italian study found that once-weekly application of probiotics for 6 months almost completely prevented recurrence at 6 months (96%), and was still effective at 12 months. Studies state that when administered locally they produce specific lactobacilli strains which have been found to exert an inhibitory effect on C. albicans and organisms causing BV in invitro studies and invivo studies.4 Some studies mention the use of oral probiotics can also lead to attain effective concentration of lactobacillus intra vaginally and can be effective in treatment of VV.4 Probiotics are considered safe with, least adverse effects of local irritation and inflammation on local application, however rarely a study in Finland during 1995-2000 showed only in a mean of 0.2% of positive blood cultures in Finland were lactobacillus isolates, 32 lactobacillemia, infectious endocarditis, 33 liver abscess, 35 fungemia have been associated to probiotics.4 Thus our study investigates the possible usage of probiotics in therapy for vulvovaginitis and its efficacy, effectiveness, best route of administration and adverse effect monitoring and safety profile of the drug.
6.3 Objectives of study:
·  To determine effect of probiotics oral / local as adjunct to standard therapy in treatment and prevention of recurrence in vulvovaginitis.
·  To compare efficacy of probiotics in bacterial vaginosis, vulvo vaginal candidiasis and other non specific causes.
·  To determine the most effective route of administration of probiotics in vulvovaginitis.
·  To asses safety profile of adjunct probiotics in treatment of vulvovaginitis
Materials and Methods:
Study type: open labeled RANDOMISED CONTROL TRIAL
7.1 Source of Data: Patients diagnosed with symptoms and signs of vulvo vaginitis, attending OBG department of Father Muller Medical College Hospital will be screened based on criteria given below.
7.2 Method Of Collection Of Data:
Sample Size: 90
Eligibility :
Age group Eligible for the Study : / 18 to 60 Years
Genders Eligible for Study : / Female
Criteria :
Inclusion Criteria:
·  Females (age 18-60 years).
·  Clinical Diagnosis of vulvo vaginitis.
Exclusion Criteria:
·  Pregnancy,
·  HIV, on steroids therapy (immune compromised)
·  Hospitalized patients with poor general condition.
·  Major surgery, 3 months prior to Visit 1.
·  Significant co morbid diseases.
·  History of unexplained fever and sepsis. History of any other genital pathology or neoplasia.
·  Hypersensitivity reactions to lactic acid derivatives.
Diagnostic criteria for vulvo vaginitis :
Symptoms and signs: WDPV, vaginal burning sensation, excoriation, itching, dysperunia, signs of vaginitis and cervicitis.
Investigations : 3swabs of discharge collected
o  First for gram staining , Ph measurement by strip test
o  Second for KOH wet mount preparation
o  Third one for whiffs test.
No of visits :
o  Visit 1: Informed consent, sample collection for investigations, randomized treatment protocol started for 7 days.
o  Visit 2: At the end of 7 days, re exam clinically, and check for compliance, and ADR if any.
o  Visit 3: At the end of 30 days patients are again reexamined and check for recurrence in between.
Grouping: Patients fulfilling the above mentioned criteria will be recruited for the study. Initially Consent will be taken, then clinical examination, followed by collecting 3 swab of discharge, patients will be randomized according to computer generated numbers and assigned to either of the following groups and started on treatment accordingly.
GROUP A: 30 patients with VV put on standard therapy only.- CONTROL
GROUP B : 30 patients with VV put on std therapy+ oral probiotics TRIAL
GROUP C : 30 patients with VV put on std therapy + local probiotics .
CONTROL / TRIAL
Diagnosis / VV / VV / VV
Number / 30 / 30 / 30
Group / A / B / C
Treatment Plan / Std Rx Only / Std Rx + oral probiotics / Std Rx
+
local probiotic
·  Std Rx : kit of Azithromycin 1g 1 tablet, Secnidazole 1g 2 tablets, Fluconazole 150mg 1tablet stat orally , followed by tab containing clotrimazole 200mg +tinidazole 500 mg intra vaginal 1 hs for 7 days.
·  Oral probiotic used is Lactobacillus acidophilus, 150 million spores oral, 1 OD for 7 days.
·  Local probiotic used is Lactobacillus acidophilus acidophilus 150 million spores. Intra vaginal tablets, 1HS for 7 days.
Thus the patients put on treatment according to above table for 1 week by randomly computer generated numbers, are followed up for 1month. During the follow-up enquiry will be done about the the clinical compliance and adverse effects to the drug. At the end of 1 month patients will be checked for cure rates and recurrence.Results will be analysed by frequency, percentage, chi square test and ANOVA test.
In the event of increased side effects, discomfort, withdrawal such patients will be excluded from the study and appropriate care will be taken. Compliance of the patients will be maintained by education, reassurance, interactive participatory technique and telephonic reminders.
Data analysis:
Data analysed by frequency,percentage, chi square test and by ANOVA.
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals?
Yes, following tests need to be done
ph measurement of lateral walls of vagina by strip test.
Grams staining of discharge
Whiffs test or KOH wet mount preparation
7.4 Has ethical clearance been obtained from your institution?
Yes.
References :

1)Reid G, Bruce AW, Fraser N, Heinemann C, Owen J, Henning B. Oral probiotics can resolve urogenital infections. FEMS Immunol Med Microbiol.2001 Feb;30(1):49-52.

2) Hillier SL, Nugent RP, Eschenbach DA, Krohn MA, Gibbs RS, Martin DH, Cotch MF, Edelman R, Pastorek JG 2nd, Rao AV, et al. Association between bacterial vaginosis and preterm delivery of a low-birth-weight infant. The Vaginal Infections and Prematurity Study Group. N Engl J Med.1995 Dec 28;333(26):1737-42.

3) Murina F, Graziottin A, Felice R, Radici GL, Di Francesco S. The recurrent vulvovaginal candidiasis: proposal of a personalized therapeutic protocol. ISRN Obstet Gynecol.2011;2011:806065. doi: 10.5402/2011/806065.

4) Falagas ME, Betsi GI, Athanasiou S. Probiotics for prevention of recurrent vulvovaginal candidiasis: a review. J Antimicrob Chemother.2006 Aug;58(2):266-72.

5) Mastromarino P, Vitali B, Mosca L. Bacterial vaginosis: a review on clinical trials with probiotics. New Microbiol.2013 Jul;36(3):229-38.

6) Reid G, Burton J. Use of Lactobacillus to prevent infection by pathogenic bacteria. Microbes Infect.2002 Mar;4(3):319-24.

7) Rathod SD, Klausner JD, Krupp K, Reingold AL, Madhivanan P. Epidemiologic
features of Vulvovaginal Candidiasis among reproductive-age women in India.
Infect Dis Obstet Gynecol.2012;2012:859071. doi: 10.1155/2012/859071.
PATIENT INFORMATION SHEET
We are conducting a study titled “ COMPARATIVE ASSESSMENT OF PROBIOTICS AS AN ADJUNCT TO STANDARD THERAPY FOR VULVO VAGINITIS ” where we require your cooperation in seeing the effectiveness of Probiotics either orally or locally as an add on to the standard therapy . You will be given either standard therapy only or standard therapy + probiotics as chosen by random order.
Probiotics are substances prepared from yogurt/ curd, like nutrition supplement they almost have nil to minimal side effects, claimed to be useful in treatment of vulvo vaginitis / vulvo vaginal white discharge disease effectively and also to prevent future recurrence than standard therapy alone.
Your cooperation is required in taking the regimen for 1 week as advised and consent for collecting the test swabs from local area, at the beginning and end of the treatment if needed. Relevant details from your case files will also be required.
We do not expect any problems inspite of the addition of probiotics to standard therapy for 1
week at given dosage as shown by similar studies conducted in the past. You are free to withdraw from this study as and when you please. All this information that we gain will help us in treating patients with vulvo vaginitis/ white discharge disease like you to get the best therapy. You can contact us at any time if you have any query or problem regarding the same.
CONTACT:
Dr. Praveen Kumar B
Postgraduate Resident
Department Of Pharmacology,
Father Muller Medical HospitalKankanady
Mangalore- 575 002
Contact Details :
Mobile : +91-9844603899
e-mail :

CONSENT FORM

I have read the Patient Information Sheet and have discussed with the study investigator,

about the purpose of the study. I have been given the opportunity to ask questions, which

have been answered to my satisfaction. I understand that any questions that I might have asked

will be answered verbally or if I prefer, with a written statement.

I understand that my participation in this study is voluntary and that I may refuse to

participate. I also understand that if, for any reason, I wish to discontinue my participation

in this study at any time, I will be free to do so.

If I have any questions concerning my rights as a research subject in this study, I may

contact the study investigator at any time point.

As I am fully informed of the study and its purpose, I hereby consent to involve myself in

this study. I have received a signed copy of this consent form.

I understand that as a participant in this study my identity, medical records, and data

relating to this research study will be kept confidential except as required by the law.