Lactobacilli versus antifungals for vaginal candidiasis

Lactic acid bacteria help to defend against infections and, best of all, there is no risk of resistance developing. but can they keep up with antifungals?

What role does the local microbiome play in vaginal candidiasis?

In healthy women, the vaginal microbiome is in equilibrium. It is dominated by the health-promoting lactobacilli.
If the vaginal microbiome is disturbed, there is an increased susceptibility to vaginal infections, including candidosis (also known as candidiasis).
An increasing problem in the treatment with antimycotics is resistance. In addition, the substances could negatively influence the local microflora.
Lactobacilli, on the other hand, contribute to the regeneration of the vaginal mucosa.

What advantage do lactobacilli have over azoles?

Vulvovaginal candidiasis is widespread, affecting 70–75% of women at some point in their lives. This makes it all the more important to have effective and well-tolerated remedies for this unpleasant condition. However, although antimycotics such as azoles are a good treatment option, their use is becoming increasingly problematic due to resistance, which in turn increases the risk of recurrence.

The Lactobacillus plantarum strain P17630 has the special ability to attach to the vaginal epithelium and displace pathogenic Candida species. It can survive in a wide range of temperatures and pH levels and is not affected by antimycotics. The Italian researchers working with Chiara Bertarello selected it for comparison.

How was the treatment effectiveness determined?

For their randomised, controlled, and multicentre study, they recruited 200 adult women between the ages of 18 and 45 who suffered from vulvovaginal candidiasis. They were randomised 1:1 and received vaginal soft capsules containing:

100,000 colony-forming units of the Lactobacillus plantarum strain P17630 or
400 mg miconazole nitrate.

The treatment was initially given for 3 days and continued if the symptoms had not yet completely subsided by then. The success was measured by the vaginitis symptoms that included vaginal itching, discharge, pain, and vaginal dryness. These were recorded daily in the form of a visual analogue scale (VAS). In addition, the interleukin-6 (IL6) concentration in the vaginal fluid was determined as a marker for inflammation and infection.

No significant differences between miconazole and lactobacilli

In both treatment groups, the symptoms decreased continuously from day 3 to day 6 and until the follow-up examination on day 21. With P17630, 20 women were completely symptom-free after just three days. The mean concentration of Il-6 also decreased in both groups, without significant differences being found.

No adverse events occurred in any of the women participating.

Lactic acid bacteria: no resistance, fewer relapses

L. plantarum appears to be just as effective as miconazole when used alone, with no side effects. At the same time, there is no risk of developing antimicrobial resistance. Another advantage of treatment with live microorganisms is that they restore vaginal natural bacterial colonies. In the long term, they could also help to prevent reinfection – without any side effects.

Source

Bertarello C et al. Efficacy and safety of Lactobacillus plantarum P 17630 strain soft vaginal capsule in vaginal candidiasis: a randomized non-inferiority clinical trial. Eur Rev Med Pharmcol Sci 2024; 28:384–391.