Oral and Vaginal Lactobacillus Ineffective in Preventing Postantibiotic Vulvovaginal Candidiasis

Yael Waknine

August 30, 2004

Aug. 30, 2004 -- Oral and vaginal probiotic treatments containing primarily Lactobacillus rhamnosus are ineffective in preventing postantibiotic vulvovaginal candidiasis, according to the results of a randomized, placebo-controlled, double-blind study reported in the Aug. 27 Online First issue of the British Medical Journal.

"Probiotics are commonly used and recommended for vulvovaginitis that develops after antibiotic treatment -- a condition of concern to many women and usually caused by Candida albicans," writes Marie Pirotta, MD, from the University of Melbourne in Australia, and colleagues. "Our previous study found that 40% of a sample of 751 women with a history of vulvovaginitis had used yoghurt or lactobacillus orally or vaginally to prevent post-antibiotic vulvovaginitis."

To explore the effectiveness of this treatment, the investigators recruited 278 nonpregnant women aged 18 to 50 years requiring a short course of oral antibiotics for a nongynecological infection within 48 hours of enrollment.

The women were randomized to receive one of four treatments during the antibiotic course (six days) and for four days afterward: oral and vaginal lactobacillus (n = 67), oral lactobacillus and vaginal placebo (n = 73), oral placebo and vaginal lactobacillus (n = 70), and oral and vaginal placebo (n = 68).

Surveys and vaginal swabs were taken at baseline and at follow-up 14 days after enrollment or onset of vulvovaginitis symptoms. The primary outcome measure was symptomatic vulvovaginal candidiasis, defined as symptoms (vaginal itching with or without discharge) confirmed by isolation of Candida from the follow-up swab. Compliance with the treatments was high among 234 patients who provided complete data.

Postantibiotic vulvovaginitis developed in 23% of patients (95% confidence interval [CI], 18% - 29%). Compared with placebo, the odds ratio for developing vulvovaginitis while taking oral lactobacillus was 1.06 (95% CI, 0.58 - 1.94), and 1.38 (95% CI, 0.75 - 2.54) while taking vaginal lactobacillus.

According to these results, the chances of a significant reduction in vulvovaginitis with oral or vaginal lactobacillus were poor (0.032 and 0.0006, respectively), and the trial was ended prematurely. "It was considered unethical to continue recruitment to a trial with no potential benefit," the authors note.

"The use of lactobacillus in post-antibiotic vulvovaginitis is an example of a treatment that has widespread use despite lack of a biologically plausible basis or evidence of effectiveness," the authors write. "Our results should prompt health professionals to inform women that lactobacillus is unlikely to prevent post-antibiotic vulvovaginitis and that they should consider using proved antifungal treatment if symptoms develop."

The study was funded by a Quality Use of Medicine Scholarship from the Australian Commonwealth Department of Health and Aging, the Shepherd Foundation, the Royal Australian College of General Practitioners, Nutrition Care, Institut Rosell, Health Care Network, and Sean Howard.

One investigator received active treatments, placebos, and research funding from Nutrition Care and Institut Rosell.

BMJ. Published online Aug. 27, 2004.

Reviewed by Gary D. Vogin, MD

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