Editors' ChoiceMicrobiome

A whiff of change for dysbiosis treatment

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Science Translational Medicine  13 Nov 2019:
Vol. 11, Issue 518, eaaz9750
DOI: 10.1126/scitranslmed.aaz9750

Abstract

Vaginal microbiome transplantation might be a safe and effective treatment in patients with intractable bacterial vaginosis.

Bacterial vaginosis is a form of microbial dysbiosis in which anaerobes dominate the vaginal microbiome, with concomitant decreases in Lactobacillus species. Affecting up to one-third of women of reproductive age, this condition can be characterized by malodorous vaginal discharge and negative impacts on fertility, pregnancy, and susceptibility to sexually transmitted infections. Standard treatment consists of local or systemic antibiotics, but relapse rates can be as high as 70% within one year. The success of fecal microbiome transplantation for severe recurrent C. difficile colitis has prompted Lev-Sagie et al. to conduct an exploratory clinical trial of vaginal microbiome transplantation (VMT) in women with intractable bacterial vaginosis.

After a course of topical antibiotics, five patients underwent VMT. Each time of symptom recurrence or with reappearance of one or more clinical criteria (characteristic discharge; vaginal pH > 4.5; fishy odor when adding potassium hydroxide solution to wet mount, i.e., the so called “whiff test”; and increase in bacteria-covered “clue cells” on wet mount microscopy), VMT was repeated. With this approach, four patients had long-lasting disease remission until the end of follow-up at 5 to 21 months. The fifth patient showed partial improvement as evidenced by reduced clinical but not microscopic alterations. In one patient, a change in donor was necessary to achieve remission. Another patient experienced disease recurrence after requiring oral antibiotics for pharyngitis but was again successfully treated with a repeated course of VMT. Clinical and microscopic improvements were confirmed by using metagenomic sequencing of the patients’ microbiomes before and after treatment. Four of the five VMT recipients exhibited a drastic change in microbiome composition within the first month after VMT, correlating with improvements in clinical criteria and patient symptoms, increases in members of the Lactobacillus genus, and concomitant decreases in Bifidobacterium genus members.

Larger placebo-controlled trials will be needed to confirm efficacy and safety, including the transfer of antibiotic-resistant microbes or the potential for unintended pregnancy due to sperm contamination. Nevertheless, this study shows the feasibility of VMT as a long-term treatment solution for hard-to-treat bacterial vaginosis and encourages further studies in other diseases associated with microbial dysbiosis.

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