Highly Acidifying Intravaginal Rings with Lactobacillus Probiotics to Treat Bacterial Vaginosis

摘要 美国有数百万妇女患有细菌性阴道病（BV），这是一种由明显的阴道炎引起的阴道疾病。 可抑制保护性乳酸杆菌的多微生物细菌群体的过度生长。健康乳酸菌 (LB)，特别是卷须，分泌乳酸（LA），酸化阴道，并作为一个广泛的- 一种广谱杀微生物剂，可防止多种病原体，也可抑制多种微生物 产生很少或不产生乳酸的BV物种群落。我们不知道是什么引发了BV发作， 但我们知道BV会大大增加许多性传播感染的风险，包括艾滋病毒， 增加早产的风险。在任何时候，美国约有三分之一的性活跃女性， 全世界都有BV。抗生素可以暂时缓解BV引起的恶臭分泌物， 它们不能防止BV复发（有时频率高达每月两次）。没有产品 市场可以提供持续的保护，防止细菌性阴道炎。我们和其他人已经证明，洛杉矶可以有力地 许多类型的BV相关细菌以及许多类型的病原体， 传播感染。由于LA在具有保护性LB的女性的健康阴道中丰富，特别是在 对于患有卷曲乳杆菌（Lactobacillus crispatus，L.c）的女性，它有可能成为一种安全的非抗生素杀微生物剂。 我们最近已经确定了健康乳酸杆菌持续产生LA的速率， 第一次知道乳酸应该以什么速度供应到阴道来治疗和预防BV。这 这一转变指导我们开发了一种释放LA的阴道环（LA-IVR）， 在30天内以治疗和预防BV所需的速率释放LA，同时不抑制健康的LB。我们 进一步合成了猕猴大小的LA-IVR，当插入猕猴阴道时，可以降低 阴道pH基本上没有引起任何毒性。在我们充满希望的工作的基础上，我们力求将联合收割机 LA-IVR与含有冻干L. c粉末的胶囊形式的L. c益生菌一起使用，以实现 协同改变阴道环境，以最好地促进重建L.c. 微生物群落在目标1中，我们计划根据生长速率和酸化速率确定L.c的一种先导菌株 和程度，然后将它们配制成冻干粉并装入胶囊。在目标2中，我们将制造 macaque大小的LA-IVR，并测试是否通过该IVR与 L. c益生菌胶囊可抑制猪尾猕猴体内BV样细菌种类。成功示范 在这种高度相关的大型动物模型中的安全性和有效性将支持 Mucommune可以通过IND使能活动推进的最佳LB-LA-IVR。我们的LA-IVR的简单性 和L. c装载的胶囊设计确保了易于生产和可能非常低的制造成本。 最终产品，这反过来又应该最大限度地提高潜在的公共卫生影响和商业可行性， 产品在美国和世界各地的低收入和中等收入国家。

Abstract Millions of women in the U.S. suffer from bacterial vaginosis (BV), a vaginal condition initiated by marked overgrowth of polymicrobial bacterial populations that can suppress protective lactobacilli. Healthy lactobacilli (LB), in particular lactobacillus crispatus, secrete lactic acid (LA) that acidifies the vagina and acts as a broad- spectrum microbicide that protects against many types of pathogens and also can suppress polymicrobial communities of BV species that produce little or no lactic acid. We do not know what initiates episodes of BV, but we do know that BV strongly increases risks of many sexually transmitted infections including HIV, and increases risks of premature births. At any given time, about 1/3 of sexually active women in the U.S. and world-wide have BV. Antibiotics can provide transient relief from the foul-smelling discharge caused by BV but they do not prevent BV from recurring (sometimes at a frequency up to twice a month). There is no product on the market that can provide sustained protection against BV. We and others have shown that LA can potently inactivate many types of BV-associated bacteria as well as many types of pathogens that cause sexually transmitted infections. Since LA is abundant in the healthy vaginas of women with protective LB, particularly in women with Lactobacillus crispatus (L.c), it has the potential to serve as a safe, non-antibiotics microbicide. We have recently determined the rate at which healthy lactobacilli continuously produce LA and hence for the first time know the rate at which lactic acid should be supplied to the vagina to treat and prevent BV. This in turn guided our development of an LA-releasing intravaginal ring (LA-IVR) that can provide sustained release of LA over 30 days at the rate needed to treat and prevent BV while not suppressing healthy LB. We have further synthesized macaque-sized LA-IVR that, when inserted into the macaque vagina, could lower the vaginal pH substantially without causing any toxicity. Building on our promising work, we seek to combine this LA-IVR with a L.c probiotics in the form of capsules containing lyophilized L.c powder, in order to achieve a synergistic alteration to the vaginal environment to best promote the re-establishment of a L.c-dominated microflora. In Aim 1, we plan to identify a lead strain of L.c based on growth rates as well as acidification rates and extent, then formulate them into lyophilized powders and load into capsules. In Aim 2, we will fabricate the macaque-sized LA-IVRs, and test whether combinatorial treatment of sustained LA release by this IVR with the L.c probiotics capsules can suppress BV-like bacterial species in pigtail macaques. Successful demonstration of safety and efficacy in this highly relevant large animal model would support the design requirements of an optimal LB-LA-IVR that Mucommune can advance through IND-enabling activities. The simplicity of our LA-IVR and L.c loaded capsule designs ensures both ease of production and likely very low manufacturing costs of the eventual product, which in turn should maximize potential public health impact and commercial viability of the product both in the U.S. and in low and middle income countries worldwide.