Validation of a Novel Diagnostic, Prognostic Assay for Bacterial Vaginosis
Validation of a Novel Diagnostic, Prognostic Assay for Bacterial Vaginosis
Bacterial vaginosis (BV) is the commonest form of vaginitis worldwide, affecting millions of
 women. Unfortunately, recurrence rates of symptomatic BV remain extremely high, 30% at three
 months and 70-80% within a year. Given the paucity of information and data regarding
 pathogenesis of BV, the etiopathogenesis of recurrent bacterial vaginosis remains unknown.
 Accordingly, reliable, proven treatment regimens for Recurrent Bacterial Vaginosis (RBV) are
 not available.

 In 2013, the investigators published two manuscripts documenting a new qPCR based approach to
 BV diagnosis and potentially prognosis. The method (LbRC) measures the content of
 lactobacilli in vaginal samples, relative to total bacterial load. The first goal of this
 study are to validate that this metric is a reliable diagnostic of BV, by determining
 sensitivities and specificities relative to Nugent scores and Amsel criteria of healthy women
 and BV patients. A high LbRC score (3-4) corresponds to a healthy state. The second goal is
 to determine whether empirically determined "low" LbRC scores (1-2) in BV patients after
 treatment are indicators of recurrence, and whether preemptive action, based on this score,
 with more intensive treatment, delays or eliminates recurrence in these patients.
A standard of care (SOC) treatment for BV is oral metronidazole 500 mg twice a day for 7 days
 (8). The investigators will use this for all enrollees with BV as the initial treatment. The
 investigators will evaluate patients at each visit by LbRC scores; a score of 1-2 (low)
 indicates that notable levels of non-lactobacilli are present. BV subjects with clinical
 cures (Amsel) and LbRC scores of 3-4 (high) at Visit 2 will simply be monitored on a monthly
 basis with no further treatment (Group G1). The investigators expect that some Group 1
 patients will eventually recur, and that LbRC scores will drop to 1-2, two weeks prior to
 recurrence of BV symptoms, an event the investigators termed "conversion" . The investigators
 will choose randomly, using an Excel randomizer, half of the "converted" patients (Group G2)
 to be treated with a high dose metronidazole (HDM) regimen, one 750 mg metronidazole/ 200 mg
 miconazole vaginal suppository daily for 7 days, to determine if treatment initiated by the
 LbRC "warning" prevents recurrence. These randomized and re-treated Group G2 subjects will be
 moved to Group B2.

 Patients who are "cured" by Amsel criteria and Nugent score but not by LbRC score at Visit 2,
 will be randomly divided into 2 groups per pre-randomization code the laboratory has. One (B1
 Group) will be monitored monthly for up to 9 months for recurrence, with no further treatment
 in that interval. Another group (B2) will be randomized to receive the HDM treatment, and
 will be monitored for long term recurrence for up to 9 months. The Lab will notify the nurse
 as to which study number subject has been randomized to be retreated with HDM. The nurse will
 contact the subject to come in for a urine pregnancy test and for the medication and
 instructions on its use. All subjects will be asked to obtain daily vaginal samples, which
 will be stored at room temperature and returned at the next visit where more supplies will be
 obtained. Subjects will continue taking daily specimens for as long as the subject is
 enrolled and willing to do so. All subjects who return the daily samples will be compensated
 for their time with a $25 Target gift card at each visit.

 Fifty non-BV subjects with no history of "vaginitis" in the past year will be enrolled as a
 control Group H and seen monthly to monitor the LbRC in the vaginal secretions. All subjects
 will be asked to take daily dated vaginal samples and store them in supplied containers at
 room temperature and return the vaginal swabs at each monthly visit where they will receive
 more supplies for the next month of specimens. All subjects will be compensated with a $25
 gift card from Target at each scheduled visit for their time and the return of the vaginal
 swab samples.

 Subjects in Group G1 or B1 who recur with acute symptomatic BV, and randomly half of those in
 Group G1 who "convert" from a good LbRC score to a poor LbRC score without symptoms, will be
 offered to take the 7 day HDM vaginal suppository regimen for one time only. Should the
 subject relapse after taking the HDM vaginal suppositories, she will be dropped from the
 study and given a prescription for conventional or SOC treatment of her BV. Should a subject
 return with a trichomonas infection she will be dropped from the study and treated with
 prescription medication. Should a subject return with vulvovaginal candidiasis, she will be
 given a prescription for an anti-yeast medication and may continue in the study.

 Purpose of the study:

 Diagnosis: Is the sensitivity, specificity, positive and negative predictive value of LbRC
 equal to or better than Nugent Score or commercial tests (BD Affirm VIII, BV Blue, targeted
 qPCR)? Prognosis and individualized therapy: Does a poor LbRC score in post-treatment,
 "cured" BV patients predict more rapid recurrence? Does intervention with more rigorous
 treatment, based on this score, delay or prevent recurrence? The proposed pilot study is a
 randomized pilot, prospective study that will will enroll at least 50 healthy women and 140
 women with acute to recurrent BV
Inclusion Criteria:

 Inclusion Criteria For BV Subjects: (140 subjects)

 -  Premenopausal women over the age of 18 who have BV who are willing to sign informed
 consent.

 -  Positive for all Amsel criteria:

 -  Vaginal pH > 4.5

 -  Positive amine test

 -  > 20% clue cells on wet mount

 -  Grayish-white adherent discharge

 -  Subject is willing to refrain from using any vaginal medications, douches or
 spermicides except for the metronidazole suppositories that are given to her for the
 duration of the study.

 -  Subject is willing to use supplied non-lubricated condoms when sexually active. But
 not to have sexual intercourse within 48 hours of any Study Visit.

 -  Subject to refrain from alcohol for 24 hours prior to the first 7 days of the
 metronidazole treatment and for 48 hours after completion of this treatment.

 Inclusion criteria for Healthy control group.

 -  Enrollees for the healthy Group H in the study must be premenopausal and have not
 experienced any vaginitis in the past year.

 -  Subject will be encouraged to have a full clinical examination, but if she declines,
 she must have a self-swab evaluation that is normal (no yeast, no clue cells, normal
 flora, no parabasal cells and no trichomonads) and will be retained in Group H if her
 Nugent score is 3 or less.

 -  Subject must be willing to obtain daily samples and return monthly with the samples
 for a self-swab evaluation and a replenishment of the daily swab supplies. Healthy
 women will continue for as long as they are willing up to 9 months.

 -  Healthy women will be asked to use the supplied non-lubricated condoms, but will not
 be dropped from the study if they do not.

 -  Must be using some form of contraception if sexually active.

 Exclusion Criteria:

 Study Exclusion Criteria for BV Study Subjects:

 -  Mixed vaginal infection at time of enrollment.

 -  Pregnancy, nursing or planning on getting pregnant.

 -  Subject on anticoagulation therapy, lithium therapy or Antabuse therapy.

 -  Vaginal bleeding at time of enrollment

 -  Allergy to metronidazole

 -  Use of any vaginal antibiotics or antifungals in the previous 10 days, from
 enrollment.

 -  Must not require treatment for an abnormal Pap smear or genital cancer.

 -  Must abstain from vaginal douching during enrolled period.

 Study Exclusion for Control Subjects:

 -  Has a vaginal infection at enrollment

 -  Pregnant, nursing or planning on becoming pregnant in the next year.

 -  Vaginal bleeding at enrollment

 -  Must not require treatment of any genital cancer or abnormal pap smear

 -  Should abstain from douching throughout the length of the study.