Vaginitis is a common reproductive infection in women worldwide, particularly in tropical and underdeveloped countries. Traditional antibiotic treatments can disrupt the balance of beneficial bacteria, requiring repeated use, seriously affecting women's health. Therefore, probiotics are microorganisms that are beneficial to human health when consumed in sufficient amounts, playing an important role in maintaining the balance of the body's microflora, especially in the intestines and vagina. Many studies around the world have proven that probiotic strains belonging to the genera Lactobacillus, Bifidobacterium, Bacillus, and Saccharomyces can help reduce the incidence and severity of bacterial vaginal infections and yeast infections. However, the effectiveness of oral or tablet probiotics is limited due to a slow onset of action and sensitivity to acidic conditions and temperature. In this study, the investigators proposed that vaginal spray probiotics containing Bacillus strains combined with proven stability in both acidic and thermal environments, may be a safe and effective symptomatic treatment for vaginal infections due to pathogenic bacteria, viruses, fungi, and/or flagellates. This probiotic supportive therapy may offer a promising alternative to traditional antibiotic therapy by (i) inhibiting the growth of pathogenic microorganism; (ii) regulating pro-inflammatory cytokines; and (iii) improving vaginal microbiota.

The aim of the study is to evaluate the effectiveness of vaginal-spraying Bacillus probiotics in LiveSpo®️ X-SECRET (5 billion CFU/5 mL B. subtilis, B. clausii, and B. coagulans) in preventing and supporting the treatment of vaginal infections.

Study Population: The study is being carried out at Hanoi Obstetrics and Gynecology Hospital (Hanoi OGH) and Bac Ninh Center for Disease Control and Prevention (Bac Ninh CDC). The sample size is 120 per each location.

Description of Study Intervention: In each location, a total of 120 eligible patients are recruited and divided randomly into 2 groups (n = 60/group/location): Control and Experimental groups. Patients in the Control group received routine treatment and 2-3 times/day 0.9% NaCl physiological saline while patients in the experimental group were treated with LiveSpo X-SECRET 2-3 times/day in addition to the same standard of care treatment. While the standard treatment regimen lasts for 7 days, the probiotic treatment is continually maintained for 28 days.

Study duration: 8 months.

Vaginitis is a disease related to women's reproductive tract including bacterial vaginosis (Bacterial vaginosis - BV), sexually transmitted diseases (Sexually Transmitted Diseases - STDs)... This is considered is a common infection in the world, especially in developing and underdeveloped tropical countries, with up to 3/4 of the population suffering from STDs, mainly in the reproductive age group of 15-24. There are many microbial agents that cause gynecological diseases, including bacteria, viruses, fungi, flagellates... Bacterial vaginosis is an endogenous vaginal infection caused by more than 30 different species of bacteria, mainly mainly anaerobic bacteria such as Gardnerella vaginalis, Mycoplasma hominis, M. genitalium... Vaginitis is quite common in Vietnamese women. This is an issue of great concern in public health care because sexually transmitted diseases often have mild or no symptoms, so they are easy to ignore. Besides, the use of broad-spectrum antibiotics can lead to side effects such as loss of appetite, fatigue and sexual problems, while repeated treatments can lead to the appearance of antibiotic resistance, poses a significant challenge to the treatment of BV and STDs worldwide. The disease is normally caused by the replacement of Lactobacillus (a group of beneficial bacteria of the vagina) leading to an overgrowth of anaerobic bacteria. Probiotics are microorganisms that are beneficial to human health when consumed in sufficient amounts, playing an important role in maintaining the balance of the body's microflora, especially in the intestines and vagina. Studies have found that probiotics may help reduce the incidence and severity of vaginal infections, including bacterial vaginosis and yeast infections. Currently, probiotics formulated as oral capsules or gynecological suppositories containing Bifidobacterium or Lactobacillus strains are being studied as a potential adjunctive therapy for the treatment of vaginal infections. However, these strains have low viability and are sensitive to temperature, humidity and pH, making preservation difficult. Their effectiveness therefore depends on the specific strains used and the dosage required to achieve high concentrations in the vaginal tract. Beneficial bacteria of the Bacillus genus have been studied for a long time for their safety. For example, Bacillus subtilis, B. clausii and B. coagulans are often aerobic or facultative anaerobic bacteria, capable of growing rapidly and forming spores that are resistant to harsh conditions such as lack of nutrition, lack of oxygen, high temperatures and even antibiotics. In addition, these bacteria are particularly well-suited for usage as direct and in-situ probiotic vaginal sprays since they can also secrete antibacterial compounds, lactic acid, H2O2, and activate the mucosal layer of intestinal immune system. The vaginal-spraying probiotic therapy helps support the treatment and prevention of sexually transmitted pathogens, providing a promising support/alternative solution to traditional antibiotic therapy.

The aim of this study is to assess if vaginal-spraying Bacillus probiotic spores can can reduce clinical symptoms and improve various sub-clinical markers of vaginitis patients.

Methods: Prospective design of randomized, double-blind, and controlled clinical trial. The experiment was conducted on women with vaginitis and the obtained data was compared either between 2 groups or among two-to-four time points of treatment period of the same group. The control group was applied the routine treatment at the hospital combined with spraying 0.9% NaCl physiological saline into the vagina 3 times/time x 2 times/day continuously for 28 days. The test group was applied routine treatment at the hospital combined with spraying LiveSpo X-SECRET into the vagina 3 times/time x 2 times/day continuously for 28 days.

Samples are taken at day 0 and one or more of the following time points: day 3, 7, 14, and/or 28, depending on each research unit's ability to control sampling at certain intervals during the treatment procedure. In details, samples were taken at day 0, 7, and 28 at Hanoi OGH; and at day 0, 3, 7, 14, 28 at Bac Ninh CDC. Sub-clinical indicators related to vaginitis was monitored at different time points, including:

• Bacterial staining tests: These tests were conducted routinely at the Departments of Microbiology, both at Hanoi OGH and Bac Ninh CDC, at day 0 and day 28.
• Real time PCR assay to detect 9 main microorganisms that cause inflammation in vaginal swab samples: Gardnerella vaginalis (GV); Neisseria gonorrhoeae (NG); Chlamydia trachomatis (CT); Candida albicans (CA); Trichomonas vaginalis (TV); Mycoplasma hominis (MH); Mycoplasma genitalium (MG); Human alphaherpesvirus type 1 (HSV-1); Human alphaherpesvirus type 2 (HSV-2). This assay was performed at the Department of Microbiology, Fungi, and Parasitology Testing, Central Dermatology Hospital, using commercial kits or an "in-house" kit that was recently developed and published internationally by the research team (Bui et al. ., 2023). The assay was carried out at day 0, 7, and 28 for samples collected at Hanoi OGH; and at day 0, 3, 7, 14, 28 for samples collected at Bac Ninh CDC.
• Real time PCR assay to detect Bacillus sp. including B. subtilis, B. clausii and B. coagulans in vaginal swab samples. This experiment was performed at the Spobio Research Center, Anabio R&D. The assay was carried out at day 0, 7, and 28 for samples collected at Hanoi OGH; and at day 0, 3, 7, 14, 28 for samples collected at Bac Ninh CDC.
• Analysis of immune index including 5 types of cytokines IL-1β, IL-6, IL-8, IL-10, TNF-α and IgA was performed using ELISA technique from vaginal swab samples collected at days 0, 7, and 28 at Hanoi OGH only. The tests are conducted at the Department of Microbiology, Fungi, and Parasitology Testing, Central Dermatology Hospital or Spobio Research Center, Anabio R&D.
• Changes in microbiome using 16S rRNA metagenome analysis: This microbiome analysis was conducted for representative vaginal swab samples from patients of each research group (expected 10-15 patients/group) using new generation sequencing (NGS) on an Illumina MiSeq system (Illumina, San Diego, CA, USA) with a 2 × 250 bp run configuration. The assay was carried out at day 0 and one or more of the following time points day 7 and 28 for samples collected at both Hanoi OGH and Bac Ninh CDC.

Inclusion Criteria:

• Women from 18 to 60 years old
• Diagnosed with vaginitis with obvious symptoms and manifestations such as: vulvar/vaginal ulcers, inflammation, vaginal odor, vaginal itching, vaginal cololr, painful/ painful urination, lower abdominal pain; pain during sex; abnormal vaginal bleeding…
• Positive for one of the following pathogents that cause vaginitis, such as Gardnerella vaginalis, Mycoplasma hominis, Candida albicans, Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, HSV-1, HSV-2, Trichomonas vaginalis, detected by real-time PCR assay.
• The patient agrees to participate in the study, explains and signs the consent form to participate in the study.

Exclusion Criteria:

• Women who are pregnant or breast-feeding, have diabetes, are using antibiotics/anti-inflammatory drugs in the vaginal area within the previous 14 days
• Vaginal bleeding of unknown cause or cancer
• Have a history of drug allergy and hypersensitivity to any ingredient in probiotics or placebo
• Leave the study before day 7
• Simultaneous participation in another clinical trial or use of probiotics for the gynecological tract within the past 14 days
• Meets criteria for mental, cognitive, depressive or anxiety disorders
• Do not agree to participate in the study

Vagninitis infection in women.

Data or samples share that will be coded, with no PHI include. Approval of the request and execution of all applicable agreements (i.e. a material transfer agreement) are prerequisites to the sharing of data with the requesting party.

Data requests can be submitted starting 9 months after article publication and the data will be made accessible for up to 24 months. Extensions will be considered on a case-by-case basis.

Access to trial IPD can be requested by qualified researchers engaging in independent scientific research and will be provided following review and approval of a study protocol, informed consent form (ICF), clinical study peport (CSR). For more information or to submit a request, please contact anabio.rd2021@gmail.com

LiveSpo X-secret and placebo 0.9% NaCl physiological saline are indistinguishable regarding taste and smell. The color and turbidity of LiveSpo X-secret suspension is unrecognizable to investigators except the PI and analyzer due to opaque plastic container.