#Grand Rounds

Are Probiotics Useful for the Treatment of Vulvovaginal Candidiasis?

BACKGROUND AND PURPOSE:

70-75% of women will experience vulvovaginal candidiasis (VVC)
It is difficult to adequately research VVC because it is not reportable and often unconfirmed
VVC is associated with a decrease in lactobacilli and overgrowth of Candida species
Probiotics, consisting of bacteria or yeast, are live microorganisms that may provide health benefits and are regulated as dietary supplements and foods
Probiotics used for prevention and treatement of Candida include
- Lactobacillus fermentum RC-14 | Lactobacillus fermentum B-54 | Lactobacillus rhamnosus GR-1 | Lactobacillus rhamnosus GG and Lactobacillus acidophilus
Routes of administration include oral, vaginal or combined
Xie et al. (Cochrane Database Syst Rev, 2017) sought to determine the effectiveness and safety of probiotics for the treatment of VVC in non-pregnant women

Systematic Review and meta-analysis
Literature search, utilizing multiple databases, information from pharmaceutical companies and experts in the field
Included data from randomized controlled trials (RCT) using probiotics, alone or as adjuvant therapy to antifungal drugs
Probiotics were included from single or multiple species and in any preparation type/dosage/route of administration
Primary Outcomes
- Clinical cure rate: Including both ‘short-term clinical cure rate’ (zero to 14 days after treatment) and ‘long-term clinical cure rate’ (one, three and six months after treatment)
- Mycological cure rate: Including both ‘short-term mycological cure rate’ (zero to 14 days after treatment)’ and ‘long-term mycological cure rate’ (one, three and six months after treatment)
- Relapse rate: Symptom recurrence confirmed by microscopic examination or vaginal culture at one, three and six months
- Rate of serious adverse events
Secondary Outcomes
- Time to relapse | non-serious events | need for additional treatment | patient satisfaction | cost effectiveness

Data was pooled from 10 RCTs, which all used probiotics as adjuvant therapy to antifungal drugs
Women were between the ages of 16 and 50
Women did not have recurrent VVC, diabetes or immunosuppressive disorders or using immunosuppressive medications
Adjuvant probiotics vs conventional antifungal drugs alone
- Improved the short-term clinical cure rate
  - Risk Ratio (RR) 1.14, 95% CI 1.05 to 1.24; 5 trials, 695 participants
- Improved the short-term mycological cure rate
  - RR 1.06, 95% CI 1.02 to 1.10; 7 trials, 969 participants
- Decreased the relapse rate at one month
- RR 0.34, 95% CI 0.17 to 0.68; 3 trials, 388 participants
Probiotics did not impact long term clinical cure or mycological cure
Probiotics were not associated with serious adverse outcomes
Additional research is needed to assess probiotic impact on first relapse, need for additional treatment, patient satisfaction and cost effectiveness

The use of probiotics as adjuvant therapy increases rates of clinical and mycological cure while not increasing serious risk
The authors strongly caution that the primary studies used in this analysis were generally of low and very low quality and further research is still required

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