Journal Pre-proof

Probiotics for the treatment of women with bacterial vaginosis: A systematic review
and meta-analysis of randomized clinical trials

Chen Li, Tenghua Wang, Yongmei Li, Tan Zhang, Qi Wang, Jin He, Li Wang, Lujin Li,
Ning Yang, Yi Fang

PII: S0014-2999(19)30612-0
DOI: https://doi.org/10.1016/j.ejphar.2019.172660
Reference: EJP 172660

To appear in: European Journal of Pharmacology

Received Date: 13 April 2019

Revised Date: 3 September 2019
Accepted Date: 9 September 2019

Please cite this article as: Li, C., Wang, T., Li, Y., Zhang, T., Wang, Q., He, J., Wang, L., Li, L., Yang,
N., Fang, Y., Probiotics for the treatment of women with bacterial vaginosis: A systematic review and
meta-analysis of randomized clinical trials, European Journal of Pharmacology (2019), doi: https://
doi.org/10.1016/j.ejphar.2019.172660.

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Probiotics for the treatment of women with bacterial vaginosis: a

systematic review and meta-analysis of randomized clinical trials

Chen Li a, †, Tenghua Wang a, †, Yongmei Li a, Tan Zhang b, Qi Wang b, Jin He a, Li Wang a, Lujin

Li c, Ning Yang a, Yi Fang a, b, *

a
Key Laboratory of Molecular Target and Clinical Pharmacology, The Fifth Affiliated Hospital &

School Pharmaceutical Sciences, Guangzhou Medical University, Guangdong 511436, China;

b
Department of Pharmacy, Peking University People’s Hospital, Beijing 100871, China;

c
Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai

201203, China;

*
Corresponding Author: Yi Fang, E-mail addresses: phaseistudy@163.com

†
These authors contributed equally to this work.
Abstract

This systematic review and meta-analysis systematically evaluated the efficacy of probiotic

monotherapy and combination therapy for bacterial vaginosis (BV). Published randomized controlled

trials were searched in the Cochrane Library, PubMed, EMBASE, OVID Database and

ClinicalTrials.gov from the inception dates to 12 July 2019. The literature was screened and evaluated

according to the inclusion criteria, and the data were analysed by a random effect model. A chi-square

test was used to test heterogeneity between trials. This study included 14 randomized controlled trials

(RCTs), which included 1372 patients, and the cure rate of BV was analysed. Three RCTs compared

probiotics with a placebo (control) [risk ratios (RR) = 4.39, 95% CI (2.05, 9.41), P = 0.0001]. Two RCTs

compared probiotics with antibiotics (control) [RR = 1.03, 95% CI (0.38, 2.81), P = 0.95]. The remaining

9 RCTs compared the combination of probiotics and antibiotics with antibiotics alone [RR = 1.28, 95%

CI (1.05, 1.56), P = 0.02]. Despite the high heterogeneity of the pooled analysis, neither the subgroup

analysis results nor the sensitivity analysis results were statistically significant. Probiotics may have a

positive effect on the treatment of BV, but there is a lack of strong evidence.

Keywords: Probiotics, Bacterial vaginosis, Cure rate, Meta-analysis

1. Introduction

Bacterial vaginosis (BV) is one of the most common forms of vaginal dysbiosis and often disrupts the

balance between vaginal microbial and bacterial communities. Some patients may be asymptomatic, and

the clinical manifestations in other patients often include vaginal itching, increased vaginal secretions,

odour, and pain (Koumans et al., 2007; Klebanoff et al., 2004). BV plays a role in gynaecological

complications such as preterm birth, abortion, and endometritis (Hillier et al., 1995; Sobel et al., 2000;

Ness et al., 2005). Other BV-related risk factors include sexually transmitted diseases such as HIV and

cervical cancer (Cohen et al., 2012).

At present, there are two main methods for the diagnosis of BV: the clinical Amsel’s criteria and the

Nugent Score for Gram stain. A BV diagnosis requires the presence of at least 3 of Amsel’s criteria

(Amsel et al., 1983). A Nugent score (Nugent et al., 1991) of 0-3 is indicative of normal flora, and a score

of 4-6 is indicative of intermediate flora; a BV diagnosis requires a Nugent score of ≥7. Another way to

score is the Gram staining is to use the criteria by Hay & Ison (Forsum et al., 2002), which is comparable

to the Nugent score. The common cure criteria are 21-30 days after the start of treatment, a Nugent score

of 0-3, meeting no more than one of Amsel’s criteria or a Hay & Ison score equal to 1. Although the

molecular test of BV is superior to the traditional diagnostic method, it is too expensive to use widely in

clinical practice (van der Veer C et al., 2018).

The aetiology of BV is unclear, and antibiotic therapy is the main treatment to reduce symptoms of BV,

with a short-term cure rate of up to 80% (Koumans et al., 2002). The treatment mechanism has been

reported as improving the abnormal flora by the elimination of Gardnerella vaginalis and anaerobes.
However, this traditional therapy often leads to treatment failure or BV recurrence (Bradshaw et al.,

2013). After therapy with Metronidazole or Clindamycin, the long-term recurrence rate of BV is larger

than 50% (Bradshaw et al., 2006; Sobel et al., 1993). Although these antibacterial drugs are considered to

be safe, there are several side effects noted with their use (Oduyebo et al., 2009). Adverse reactions to

Metronidazole are gastrointestinal, such as nausea and vomiting. Oral Clindamycin can cause nausea,

vomiting and abdominal pain. Many female patients have used the same drug for many years, but BV

cannot be cured permanently (Sobel et al., 2015). In addition, traditional treatment methods ignore the

impact of the vaginal microbial environment on diseases and the destruction of the balance of the vaginal

microbial environment caused by antibiotic therapy (Ferrer et al., 2017; Gottschick et al., 2017). Ignoring

these factors results in poor efficacy and a high recurrence rate of BV. The treatment of BV should focus

on the treatment of clinical symptoms, a reduction in the recurrence rate, and reconstruction of the

vaginal microbial environment. New and effective treatments are urgently needed for women with BV.

With the introduction of complementary and alternative therapies (CAM), probiotics have been used to

replace some traditional therapies. The main mechanism of probiotics in the treatment of BV is to

reconstruct the vaginal microbial environment. Common probiotics include L. reuteri RC-14, L.

fermentum, L. gasseri, L. rhamnosus GR-1, L. acidophilus and L. crispatus (Borges et al., 2014). Clinical

trials have shown that these probiotics can play a positive role in restoring vaginal microecology and

treating BV (Homayouni et al., 2014). However, several trials have shown no significant effect of

vaginal lactobacillus infusion on the treatment of BV (Homayouni et al., 2014). Probiotics also avoid the

abuse of antibiotics, which can cause drug-resistant bacteria to appear. Probiotics have no side effects

and have great value in this application. Randomized controlled trials (RCTs) on probiotics for BV are
increasingly becoming available, but the efficacy of probiotics for BV therapy is still controversial.

Therefore, this study conducted a meta-analysis of the currently published RCTs on probiotics for BV to

systematically evaluate the efficacy of probiotic monotherapy and combination therapy on BV.

2. Materials and methods

2.1. Search strategy

The Cochrane Library, PubMed, EMBASE and OVID databases were searched for randomized

controlled trials on probiotics for the treatment of bacterial vaginosis that were published prior to 15

December 2018 and then updated to include publications prior to 12 July 2019. The ClinicalTrials.gov

website was also searched. We searched the literature by subject terms and free words, and references

included in the literature were read as well. The search terms included the words related to “bacterial

vaginosis”, including bacterial vaginitides, bacterial vaginoses, bacterial vaginosis, and BV, and other

words related to “probiotics”, including lactobacillus, bifidobacterium, lactobacilli, lactic acid bacteria,

and LB. The search strategies for RCTs included using the RCT filters for different databases on the

Cochrane site.

Two authors, CL and TW, independently searched the literature, completed the literature retrieval

process, and read the title and abstract of each article that was screened. These authors additionally read

the full text to determine whether the article met the inclusion criteria. The study is reported according to

the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The

PRISMA flow diagram shows the process of selecting the literature (Moher et al., 2015).
2.2. Inclusion and exclusion criteria

The inclusion criteria for considering full-text publications were the following: (a) types of studies:

randomized controlled trials with probiotics; (b) study population: non-pregnant and non-lactating

women with BV only; (c) diagnostic standards: Nugent score and Amsel’s criteria; (d) intervention:

probiotics only (regardless of the type and regimen used) or probiotics in combination with traditional

antibiotics; (e) controlled interventions: antibiotics or a placebo; (f) treatment outcomes: the Amsel’s

criteria or Nugent scores of less than 3 after 21 to 30 days of treatment.

The exclusion criteria were articles that (a) included women with HIV, HPV, other vaginal infections or

urinary tract infections; (b) did not have the full text available or was not in the English language; (c)

included duplicate data, reported insufficient data or failed to report the required results.

2.3. Quality assessment of the studies

The quality of the included literature was assessed using the "risk of bias table" recommended by the

Cochrane Handbook for Systematic Review. This assessment mainly includes 7 aspects: random

sequence generation (selection bias), allocation concealment (selection bias), blinding of participants and

personnel (performance bias), blinding of the outcome assessment (detection bias), incomplete outcome

data (attrition bias), selective reporting (reporting bias) and other bias and judgements (low risk,

unknown risk and high risk). The quality evaluation was performed by two authors (CL and TW), and

disagreements were adjudicated by discussion.

2.4. Data extraction and synthesis

Two authors (CL and TW) designed and used the same form for data extraction. cData included the

author, country, year of publication, age range, sample size, intervention measures (dosage form, strain,

quantity, course of treatment), follow-up times, and outcome indicators.

The study analysed the cure rate for BV in RCTs. We provided a list of the data for this study in the

supplementary material. The collected data demonstrated dichotomous outcomes: the outcome in the

trial group was BV-free, while the outcomes in the control group were BV and intermediate flora. If no

dichotomous data were presented in the RCT, the cure rate was converted to dichotomous data. The data

were merged using the Mantel-Haenszel method.

2.5. Statistical analysis

Meta-analysis was performed using RevMan5.3 provided by the Cochrane collaboration. The

heterogeneity among the results was tested by the chi-square test, and the I2 statistic was a quantitative

measure of inconsistency across studies. Studies with an I2＜25% are considered indicative of little

heterogeneity, 25-50% of low heterogeneity, 50-75% of moderate heterogeneity, and over 75% of high

statistical heterogeneity. Because of the different clinical designs of these RCTs, we used a random

effects model for the meta-analysis. Subgroup analysis or influence analysis was performed when the

outcome indicators were highly heterogeneous. The risk ratio (RR) were used as the efficacy analysis

statistic for the included data (RR=risk of event in experimental group/risk of event in control group=

(SE/NE)/(SC/NC)), which was expressed as a 95% confidence interval (95% CI) for each effect. For data

that could not be merged, descriptive analysis was used.

3. Results

3.1. Study identification and selection

Eight hundred and two related studies were preliminarily retrieved according to the developed retrieval

strategy. After 324 duplicates were removed, 405 were screened according to the titles and abstracts. An

additional 73 articles were excluded based on the inclusion and exclusion criteria. In the end, 14 related

documents involving 1372 participants were included in this study. The flow chart shows the process of

selecting the literature (Fig. 1).

3.2. Risk of bias assessment

The assessments of risk of bias for the included 14 RCTs are shown in Figs. 2 and 3. The risk of bias

mainly stemmed from allocation concealment (Eriksson et al., 2005; Ozmen et al., 1997; Parent et al.,

1996) and blinding of participants and personnel (Eriksson et al., 2005; Vicariotto et al., 2014). A total of

five studies were unclear or did not perform an intention-to-treat analysis (Anukam et al. a, 2006;

Anukam et al. b, 2006; Martinez et al., 2009; Parent et al., 1996; Petricevic et al., 2008). In general, the

quality of the included studies was moderate. Six of the 14 studies included one or more criteria and were

considered at high risk of bias, and only two studies did not have an uncertain risk of bias. Heterogeneity

was revealed by funnel plots, which required further analysis (Fig. 4).

3.3. Characteristics of the studies

The main characteristics of the 14 RCTs included in this meta-analysis are presented in Table 1. The

included trials were published between 1996 and 2018. Most of the studies were conducted in Europe,

and other studies were conducted in South America and Africa. There were 670 subjects in the
experimental group and 702 subjects in the control group. Three RCTs compared probiotics with a

placebo, two compared probiotics with antibiotics, and the remaining nine were randomized controlled

trials that compared the combination of probiotics and antibiotics with antibiotics alone.

3.4. Meta-analysis of treatment efficacy

A total of 14 RCTs including 1372 patients were included in this study and divided into three groups for

analysis according to the different intervention methods.

Three RCTs (Parent et al., 1996; Mastromarino et al., 2009; Vicariotto et al., 2014) compared probiotics

with a placebo and included data from 100 BV patients. In the intervention group (probiotics), 63.73%

(37/58) of patients were cured, and in the control group (placebo), five of the 42 patients (11.90%) were

cured. The results showed homogeneity between the intervention group and the control group [RR =

4.39, 95% CI (2.05, 9.41), P = 0.0001, I2=0%]. Probiotics have a therapeutic effect on BV compared with

placebo (Fig. 5).

The studies conducted by Ozmen et al. (1998) and Anukanm et al. (2006) were randomized controlled

trials comparing probiotics with antibiotics (control) in a total of 251 BV patients. Among the patients,

68 of the 117 (58.12%) patients in the intervention group (probiotics) were cured, and 106 of the 134

(79.10%) patients in the control group (antibiotics) were cured. The difference in the cure rate of BV

between the two different treatment regimens was not statistically significant [RR = 1.03, 95% CI (0.38,

2.81), P = 0.95; I2=84%]. However, due to the small number of RCTs that were selected, no further

analysis could be made (Fig. 6).

The remaining 9 RCTs (Ozmen et al., 1998; Eriksson et al., 2005; Anukam et al. b, 2006; Larsson et al.,

2008; Marcone et al., 2008; Petricevic et al., 2008; Martinez et al., 2009; Marcone et al., 2010; Laue et

al., 2018) included the data of 1021 BV patients and compared the combination of probiotics and

antibiotics with a single antibiotic; in the intervention group (combination of probiotics and antibiotics),

495 patients were cured with 388 positions (78.38%), and 333 of the 526 (66.31%) patients in the control

group (antibiotic only) were cured. The results showed that the difference in the cure rate of BV between

the two groups was statistically significant [RR = 1.28, 95% CI (1.05, 1.56), P = 0.02]. High

heterogeneity (I2=87%) indicates that the included RCTs require sensitivity analysis or subgroup

analysis (Fig. 7).

3.5. Subgroup analysis

We performed subgroup analyses to explore the substantial heterogeneity we found in the analyses

comparing the combination of probiotics and antibiotics with a single antibiotic. The test for the

subgroup of species of probiotics and regimen combinations showed that there was no statistically

significant subgroup effect (P = 0.77; P = 0.73). This result means that the two aspects likely did not

affect the therapeutic effect of probiotics. In the subgroup including the route of administration and study

population, the covariate is unevenly distributed, meaning that the analysis is unlikely to produce useful

findings. Moreover, the pooled results of these studies also showed differences between using Amsel’s

criteria [RR = 1.06, 95% CI (0.97, 1.17), P = 0.21] and Nugent score [RR = 1.63, 95% CI (1.00, 2.68), P

= 0.02]. It seems that using the Nugent score for BV diagnosis can show that probiotics were effective.

However, high heterogeneity (I2 = 90%) and insignificant subgroup differences (P = 0.10) made the
results unreliable. Overall, the effect of the intervention on this outcome was not statistically significant,

and additional adequately powered studies are needed (Table 2).

3.6. Influence analysis

The analysis of the combination of probiotics and antibiotics and antibiotics alone showed high

heterogeneity. Nine studies were removed individually, but the value of I2 was still very high. The

exclusion of any single study did not materially change the summary result, with a range from 1.18 (95%

CI 1.00, 1.39) to 1.35 (95% CI 1.07, 1.70).

4. Discussion

The review aims to systematically evaluate the efficacy of probiotic monotherapy and combination

therapy for BV. The present meta-analysis of all 14 included trials using a random effects model

illustrates that probiotics may improve the cure rate of BV but may not be a substitute for traditional

antibiotic therapy.

According to the study, patients with bacterial vaginosis who received probiotics alone had significantly

higher cure rates than those who received a placebo. This finding means that probiotics play a role in the

treatment of BV. Hallen et al. (1992) showed that 57% of 28 patients were immediately free of BV after

6 days of treatment, while none of 29 women in the placebo group were free of BV. The study established

by Hemalatha et al. (2012) found a significant decrease in IL-1β and IL-6 vaginal cytokines after a

treatment with lactobacillus, which demonstrated that lactobacillus had anti-inflammatory effects and

could cure BV. Moreover, a large multicentre RCT (Vujic et al., 2013) also suggested that oral probiotics
or vaginal capsules with probiotics can be an alternative, side effect-free treatment for bacterial vaginosis.

The conclusions of the three studies supported the review but were excluded due to the use of different

follow-up times.

Many researchers have stated that probiotics has potential to be a substitute for traditional antibiotic

treatment, but this substitution requires confirmatory evidence via a controlled trial comparing probiotics

with antibiotics. At present, there is not a sufficient number of trials to indicate that probiotics are more

effective than antibiotics. Ling et al.'s (2013) clinical cohort study indicated that Lactobacillus DM8909

is as effective as vaginal metronidazole in the treatment of bacterial vaginosis.

In the analysis of antibiotics used in combination with probiotics, probiotics are effective as an adjuvant

treatment. However, the differences between the two groups (the combined treatment group and the

control group who used antibiotics only) are not significant. Despite the high heterogeneity of the pooled

analysis, the subgroup analysis could not identify possible sources of heterogeneity. The exclusion of any

one study did not change the total RR substantially. In conclusion, probiotics may have a positive effect

on the treatment of female bacterial vaginosis. In addition, none of the studies reported significant

adverse reactions, suggesting that probiotics are safe to use.

Studies have shown that the mechanism of probiotics in the treatment of BV is as follows. On the one

hand, probiotics produce antimicrobial factors (H2O2, bacteriocins) that inhibit the growth of other

colonies (Klebanoff et al., 1991; Gillor et al., 2005). On the other hand, lactobacillus, a major species of

probiotics, can acidify the vagina. Low pH is important for preventing colonization and proliferation of
non-native vaginal organisms (Charlier et al., 2009). Additionally, probiotics can adhere and compete for

adhesion sites in the vagina (Coudeyras et al., 2008). The probiotics used in the studies we included were

selected vaginal probiotics, but we could not determine whether the probiotics had any differences in

efficacy. This lack of information also leads to uncertainty in the results. In addition, some studies

indicate that a placebo has no therapeutic effect or it is unclear whether it has a therapeutic effect, which

also increases the uncertainty in our research results. The vaginal microbial environment can also recover

the balance by itself.

Although the analysis concluded that probiotics can be considered an adjuvant treatment with antibiotics,

the difference between the treatment and control group was not significant. This result may be related to

the study protocol, as we did not examine the therapeutic effect at long-term follow-up times. Marcone et

al. (2010) showed that the efficacy of probiotics was consistent with the short-term efficacy of antibiotics

and that the long-term efficacy of probiotics significantly prevented BV recurrence. The different strains

of probiotic bacteria used were also inconsistent. Studies have shown that different ethnic groups of

healthy women have different dominant microbiota, which is also related to the insignificant role of

probiotics (Ravel et al., 2011). The clinical criteria (Amsel’s criteria and the Nugent score) do not

provide an accurate diagnosis of BV, and we hope molecular diagnostic technology can be widely used

(Ma et al., 2012). In addition, there is still no good treatment for BV, and researchers should investigate

other treatment directions, such as phage therapy and lactoferrin therapy (Javed et al., 2018; Russo et al.,

2019). In summary, we need more high-quality, standardized RCTs with large sample sizes to validate

the efficacy of probiotics. Furthermore, we need to promote the development of new diagnostic methods,

develop more comprehensive prevention and treatment regimens, and even develop personalized
probiotics to treat BV.

5. Advantages and limitations

This study is the first to conduct a meta-analysis by grouping drug regimens. Previous studies combined

different drug regimens and follow-up times, and such combined analysis can affect the results. In this

study, curative effect indicators were strictly controlled, that is, the definition of cure rate was strictly met;

for example, Amsel’s criteria ≤ 1, Nugent score 0-3 and Hay & Ison score = 1 were met. The follow-up

time of the included data was limited to 21-30 days.

This study also has limitations. The RCTs we included were biased and of medium quality.

Heterogeneity among the studies was high, and we performed the subgroup analysis but did not identify

possible influencing factors. The follow-up period in our study was limited to 21-30 days, and the effect

of probiotics on the risk of recurrence was not known. It may be possible to perform long-term analysis

of the effects of different drug regimens. Each RCT was different in terms of the course of treatment and

strains. In the combination, the antibiotics used were metronidazole, clindamycin, and tinidazole. It is not

clear if the patients had other infections.

6. Conclusion

There is currently no strong evidence that probiotic monotherapy is more effective than traditional

antibiotics, and probiotics combined with antibiotics proved to improve the healing effect, but not

significantly. The use of probiotics alone has a significant effect on improving BV symptoms. We

believe that probiotics are useful for BV treatment, but the efficacy cannot be demonstrated. Our findings
suggest that probiotics may be effective in treating BV. However, this result cannot be determined

because the quality of the studies was not ideal and heterogeneity was high. Additional high-quality,

standardized randomized controlled trials with larger sample sizes are needed to prove these

postulations.
Competing interests

The authors declare no conflict of interest.

Funding

This work was supported by the Major Project of National Science and Technology “Creation of Major

New Drugs” (no. 2020ZX09201026), from the Ministry of Science and Technology of China.

Author contributions

CL, TW and YL performed the literature search, analyzed the data and drafted the manuscript. TZ, QW,

JH and LW evaluated methodological quality and revised the manuscript. LL, NY and YF designed the

study and revised the manuscript. The final version was confirmed by all authors for submission. The

authors declare that they have no conflict of interest.

Supplemental methods

Search strategies used for PubMed:

#1 Search "Vaginosis, Bacterial"[Mesh]

#2 Search "Lactobacillus"[Mesh]

#3 Search (Bacterial Vaginitides OR Vaginitides, Bacterial OR Vaginitis, Bacterial OR Bacterial

Vaginoses OR Vaginoses, Bacterial OR Bacterial Vaginosis OR Bacterial Vaginitis OR Vaginitis,

Nonspecific OR Nonspecific Vaginitis)

#4 Search (lactobacillus OR bifidobacterium OR lactobacilli OR lactic acid bacteria OR LB)

#5 Search (randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized[tiab] OR

placebo[tiab] OR drug therapy[sh] OR randomly[tiab] OR trial[tiab] OR groups[tiab] NOT (animals

[mh] NOT humans [mh])

#6 #1 OR #3

#7 #2 OR #4

#8 #6 AND #7 AND #5

Search strategies used for Cochrane Library:

#1 MeSH descriptor: [Vaginosis, Bacterial] explode all trees

#2 ("Bifidobacterium"):ti,ab,kw (Word variations have been searched)

#3 (actobacilli):ti,ab,kw (Word variations have been searched)

#4 (actic acid bacteria):ti,ab,kw (Word variations have been searched)

#5 (“bacterial vaginitides”):ti,ab,kw (Word variations have been searched)

#6 (“bacterial vaginoses”):ti,ab,kw (Word variations have been searched)

#7 (“bacterial vaginitis”):ti,ab,kw (Word variations have been searched)

#8 #5 OR #6 OR #7 OR #1

#9 MeSH descriptor: [Probiotics] explode all trees

#10 (lactobacillus):ti,ab,kw (Word variations have been searched)

#11 #9 OR #10 OR #2 OR #3 OR #4

#12 #8 AND #11

Search strategies used for ClinicalTrials.gov:

Completed Studies | (bacterial vaginosis OR bacterial vaginitides OR bacterial vaginoses OR bacterial

vaginitis OR BV) AND (probiotics OR lactobacillus OR bifidobacterium OR lactobacilli OR lactic acid

bacteria OR LB)
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Legend to Figures:

Fig.1. PRISMA Flow Diagram

Fig.2. Risk of bias graph: review authors' judgements about each risk of bias item presented as

percentages across all included studies.

Fig.3. Risk of bias summary: review authors' judgements about each risk of bias item for each included

study.

Fig.4. Funnel plot for risk of bias.

Fig.5. Forest plot showing the efficacy of probiotics compared with placebo.

Fig.6. Forest plot showing the efficacy of probiotics compared with antibiotics.

Fig.7. Forest plot showing the efficacy of probiotics combined antibiotics compared with antibiotics

alone.
Fig.1.
Fig.2.
Fig.3.
Fig.4.
Fig.5.
Fig.6.
Fig.7.
Table 1. Characteristics of the included studies in the meta-analysis

References country Type Age No. of Treatment Group Follow-up Endpoint criteria

of patients Intervention Control (days)

study (Intervention

/Control)

Parent(1996) 1 (Parent Belgium R, PC 18-50 32（16/16） 1-2 daily vaginal tablets of L. 1-2 daily vaginal tablets which did not 28 Amsel’s criteria ≤ 1

et al., 1996) acidophilus (106 CFU) plus 0.03 mg contain either probiotic or oestrol for 6

estriol for 6 days. days.

Mastromarino(2009) 1 Italy R, DB, 18-post 34（18/16） Daily vaginal tablet of L. brevis CD2, Daily vaginal tablet containing placebo 21 Nugent score 0-3

(Mastromarino et al., PC menopau L. salivarius FV2, and L. plantarum preparation did not contain lactobacilli

2009) sal FV9 (109 CFU) for 7 days. for 7 days.

women
Vicariotto(2014) 1 Italy R, PC 18-50 34（24/10） Daily a vaginal tablet of L. fermentum The placebo tablets containing an 28 Nugent score 0-3

(Vicariotto et al., LF15 and L. plantarum LP01 for 7 equivalent quantity of two inert

2014) consecutive nights. The amount of each ingredients for 7 days.

strain was 400 million live cells per

dose.

Ozmen a(1997) 2 Turkey R, NB 18-53 211 (114/97) Daily vaginal suppository of L. Oral Metronidazole 500mg twice daily 22-35 Amsel’s criteria ≤ 1

(Ozmen et al., 1998) acidophilus(107-7×108 CFU), 600mg for one week.

lactose and 0.03mg estriol for 12 nights.

Anukam a (2006) 2 Nigeria R 15-50 40（20/20） Vaginally two gelatin capsules 0.75% Metronidazole vaginal gel to the 30 Nugent score 0-3

(Anukanm et al. a, containing L. rhamnosus GR-1 and L. vagina twice a day (once in the

2006) reuteri RC-14 (1×109 each organism) at morning, once in the evening) for 5

bedtime for 5 days. days.

Ozmen b(1997) 3 Turkey R, NB 18-53 210 (114/96) Twice daily oral Metronidazole 500 mg Oral Metronidazole 500 mg twice daily 22-35 Amsel’s criteria ≤ 1

(Ozmen et al., 1998) for 1 week plus one vaginal suppository for 1 week.

containing L. acidophilus

(107-7×108 CFU), 600mg lactose and

0.03mg estriol.

Eriksson(2005) 3 Sweden R, DB, 18-53 187 (91/96) Vaginal 100 mg Clindamycin ovules for Vaginal 100 mg Clindamycin ovules for 28 Amsel’s criteria ≤ 1

(Eriksson et al., 2005) PC 3 days, then vaginal administration 3 days, then vaginal administration

tampons containing L. gasseri, L. casei placebo tampons during the next

rhamnosus, L. fermentum (108 CFU) menstrual period.

during the next menstrual period.

Anukam b (2006) 3 Nigeria R, DB, 18-44 106 (49/57) Oral Metronidazole 500 mg b.i.d. for 7 Oral Metronidazole 500 mg b.i.d. for 7 30 Nugent score 0-3

(Anukam et al. b, PC days and oral capsules containing L. days and oral capsules containing

2006) rhamnosus gR-1 and L. reuteri RC-14 placebo b.i.d. for 30 days starting on
 (109 CFU) for 30 days starting on day 1 day 1 of Metronidazole treatment.

of Metronidazole treatment.

Larsson (2008) 3 Norway R, DB, 18.8-53. 100（50/50） Daily 2 % vaginal Clindamycin cream Given a 7-day course of daily 2 % 30 Hay & Ison score =

(Laue et al., 2018) PC 6 for 7 days directly followed by vaginal vaginal Clindamycin cream directly 1

gelatine capsules containing L. gasseri followed by vaginal gelatine placebo

and L. rhamnosus (108-9 CFU), capsules, sufficient for 10 days or until

sufficient for 10 days or until menstruation commenced.

menstruation commenced.

Marcone(2008) 3 Italy R, NB 18-40 84 (42/42) Oral Metronidazole 500 mg twice a day Oral Metronidazole 500 mg twice a day 30 Amsel’s criteria ≤ 1

(Marcone et al., 2008) for 7 days followed by vaginal for 7 days.

application (one tablet containing 40

mg, i.e. (40,000 CFU) of freeze- dried

 L. rhamnosus once a week at bedtime

for 2 months starting 1 week after the

last antibiotic administration.

Petricevic (2008) 3 Austria R, OB 18-45 190 (95/90) Oral Clindamycin 300 mg twice a day Oral Clindamycin 300 mg twice a day 28 Nugent score 0-3

(Petricevic et al., for 7 days. Vaginal Lactobacillus for 7 days.

2008) capsule contained L. casei rhamnosus

(Lcr35, 109 CFU) for 7 days after

antibiotic treatment.

Martinez (2009) 3 Brazil R, DB, 16-51 64 (32/32) A single dose of Tinidazole (2g) plus A single dose of Tinidazole (2g) plus 2 28 Nugent score 0-3

(Martinez et al., 2009) PC either 2 oral capsules of L. rhamnosus placebo capsules taken daily in the

GR-1 and L. reuteri RC-14 daily in the morning for 28 days, starting on the

morning for 28 days. first day of Tinidazole use.

Marcone (2010) 3 Italy R, NB 18-45 46 (23/23) Oral 500 mg of Metronidazole followed Treated with a twice daily dose of 500 30 Amsel’s criteria ≤ 1

(Marcone et al., 2010) by vaginal application once a week for mg of oral Metronidazole for 7 days.

6 months of a capsule containing 40 mg

of L. rhamnosus (N40000 CFU)

beginning 8 days after the

Metronidazole therapy was

discontinued.

Laue (2018) 3 (Laue et Austria R, DB, ≥18 34（17/17） Oral Metronidazole for 7 days (2×500 Oral Metronidazole for 7 days (2×500 28 Amsel’s criteria ≤ 1

al., 2018)) PC mg/d). Twice daily 125g mg/d). Twice daily placebo

yoghurt containing living strains of L. which chemically acidified milk

crispatus, L. gasseri, L. rhamnosus, and without bacterial strains during 4

L. jensenii during 4 weeks. The weeks.

concentration of each strain was

 adjusted for maintenance to at least

1×107 CFU/ml.

1 Probiotics / Placebo

2 Probiotics / Antibiotics

3 Antibiotics+Probiotics / Antibiotics(+Placebo)

R randomized, DB double blind, PC placebo controlled, NB not blind, OB observer blind, CFU colony-forming units
Table 2. The summary of subgroup analyses results

Outcome No. No. RR (95% CI) P value I 2, % Test for

patients trials subgroup

differences

All included trials 1021 9 2.23 [1.63, 3.05] 0.02 87% -

Species of probiotics

Single species 530 4 1.24 [0.94, 1.65] 0.13 92% P=0.77

Multiple species 491 5 1.33 [0.92, 1.93] 0.13 87%

Endpoint criteria

Amsel’s criteria 561 5 1.06 [0.97, 1.17] 0.21 35% P=0.10

Nugent score 460 4 1.63 [1.00, 2.68] 0.02 90%

Route of administration

Orally 204 3 1.81 [1.46, 2.25] 0.33 11% P=0.0006

Vaginal application 817 6 1.11 [0.92, 1.32] 0.27 83%

Regimens of combination

Clindamycin 477 3 1.19 [0.67, 2.11] 0.55 93% P=0.73

Azoles 544 6 1.33 [1.06, 1.66] 0.01 87%

Study population

Europe 851 7 1.14 [0.96, 1.36] 0.13 82% P=0.0004

Non-Europe 170 2 1.97 [1.54, 2.53] 0.39 0%