Intravaginal LACTIN-V for Prevention of Recurrent Urinary Tract Infection

Purpose: The purpose of this study is to evaluate the safety of the vaginal suppository
LACTIN-V (Lactobacillus crispatus CTV-05) as well as the efficacy of LACTIN-V use in
preventing recurrent urinary tract infections (RUTI) in women. Study subjects will include
pre-menopausal women with a history of frequent RUTI. As part of this study, we will also
evaluate growth of lactobacilli and urinary tract infection(UTI)-causing bacteria in the
vaginas of women following use of LACTIN-V.

Rationale: LACTIN-V is composed of L. crispatus. L. crispatus is a bacteria found to grow
naturally in the vaginas of healthy women. It is felt to be important in preventing vaginal
infection and UTI. With regard to prevention of UTI, L. crispatus is thought to prevent the
growth of UTI-causing bacteria (such as E. coli) in the vagina, and so prevent these
UTI-causing bacteria from being able to enter the female urethra and cause infection in the
bladder (cystitis). There is epidemiologic evidence to support this prevention mechanism, as
absence of L. crispatus and related lactobacilli from the vagina has been associated with
vaginal E. coli growth and with UTI. Scientific evidence supports the ability of
lactobacilli to prevent vaginal E. coli growth by out-competing E. coli in vaginal
colonization, and through the production of toxins such as lactic acid, hydrogen peroxide,
and bacteriocins.

LACTIN-V contains a specific strain of L. crispatus, CTV-05, which was isolated from the
vagina of a healthy woman. It was prepared as a vaginal suppository with the purpose of
restoring growth of healthy L. crispatus in the vaginas of women who experience frequent
RUTI. As indicated above, these women often have a deficiency of healthy vaginal
lactobacilli growth, and therefore may not experience the protective function of these
natural organisms. It is hoped that use of LACTIN-V will lead to vaginal growth of
protective lactobacilli in these women wich will, in turn, prevent the vaginal growth of E.
coli and other UTI-causing bacteria. Phase 1 and 2 studies of LACTIN-V to date have shown
this "probiotic" to be safe and well tolerated.

The impetus for this study is the urgent need for non-antibiotic strategies to prevent UTI.
UTI is one of the most common bacterial infections. It leads to substantial morbidity and
health care costs. Frequent use of antibiotics for treatment of and prophylaxis against UTI
is contributing to the prevalence of antibiotic resistant bacteria, which are also making it
more difficult to treat UTI. Therefore, the potential advantage of LACTIN-V is that it is a
natural product that may prevent UTI without the use of antibiotics. If it proves to be
efficacious, it could decrease the morbidity and health care costs associated with UTI as
well as decrease overall antibiotic use and the corresponding prevalence of antibiotic
resistance among UTI-causing bacteria.

Primary Objective: The primary objective is to evaluate the safety of LACTIN-V, compared to
placebo, in pre-menopausal women with recurrent uncomplicated UTI.

Secondary objectives:

1. To evaluate the efficacy of LACTIN-V, compared to placebo, in reducing the incidence of
Symptomatic and Probable UTI (defined below).

2. To evaluate the efficacy of LACTIN-V, compared to placebo, in decreasing the time to
recurrence of Symptomatic and Probable UTI.

3. To evaluate the efficacy of LACTIN-V, compared to placebo, in reducing the prevalence
of Asymptomatic UTI (defined below).

4. To evaluate vaginal growth of CTV-05 in subjects using LACTIN-V compared to placebo.

5. To evaluate vaginal growth of lactobacilli in subjects using LACTIN-V compared to
subjects using placebo.

6. To evaluate vaginal growth of E. coli in subjects using LACTIN-V compared to subjects
using placebo.

Case Definitions:

Symptomatic UTI: One or more UTI symptoms (dysuria, urgency, frequency, suprapubic pain,
flank pain), with a positive urine culture. In symptomatic subjects, a positive urine
culture is defined as >= 10^2/ml of an UTI-causing bacteria. UTI episodes will be recorded
as Symptomatic UTI if a negative urine culture at Visit 2, or at another interim study
visit, confirms resolution of the prior UTI (in order to distinguish a new Symptomatic UTI
from a Persistent UTI).

Asymptomatic UTI: A positive urine culture in a subject who reports no urinary symptoms. In
asymptomatic subjects, a positive urine culture is defined as >= 10^5/ml of an UTI-causing
bacteria. UTI episodes will be recorded as Asymptomatic UTI if a negative urine culture at
Visit 2, or at another interim study visit, confirms resolution of the prior UTI (in order
to distinguish a new Asymptomatic UTI from a Persistent UTI).

Probable UTI: One or more UTI symptoms (dysuria, urgency, frequency, suprapubic pain, flank
pain) in a subject who contacted a healthcare provider and was treated with antibiotics for
a UTI without confirmatory urine culture. UTI episodes will be recorded as Probable UTI if a
negative urine culture at Visit 2, or at another interim study visit, confirms resolution of
the prior UTI (in order to distinguish a new Probable UTI from a Persistent UTI).

Persistent UTI: A positive urine culture following antibiotic treatment for a UTI.

General Procedures: This will be a randomized, double-blind, placebo-controlled trial of
LACTIN-V. Subjects will include 100 pre-menopausal women with a history of frequent RUTI who
are currently or recently being treated for a symptomatic UTI with
trimethoprim-sulfamethoxazole. Trimethoprim-sulfamethoxazole is one of several antibiotics
considered standard-of-care for treatment of symptomatic UTI. Subjects will be randomized
such that 50 women will receive LACTIN-V at a dose of 5x10^8 CFU/suppository and 50 women
will receive placebo. LACTIN-V and placebo are to be taken once per day for five days during
the first week of use followed by once per week for 10 weeks on Days 8, 15, 22, 29, 36, 43,
50, 57, 64, and 71 for a total of 15 doses over 11 weeks. Subjects will undergo five
scheduled visits and receive two telephone calls:

Visit 1 is the Screening Visit. This visit will take place during or soon after evaluation
for a symptomatic UTI. The following will occur during Visit 1: informed consent, review of
eligibility, history, physical exam, pelvic exam, Pap smear, urine pregnancy test, and
screening tests for gonorrhea, chlamydia, bacterial vaginosis, yeast, and trichomonas.
Subjects will provide urine samples for microscopic analysis, dipstick analysis, culture,
and antibiotic susceptibility testing and vaginal fluid specimens for laboratory assessment
of vaginal growth of lactobacilli (including CTV-05).

Visit 2 is the Randomization Visit and represents Week 1 of the study. Visit 2 will take
place 3-10 days after completion of antibiotic therapy for UTI. Subjects will have their
eligibility confirmed and undergo a focused pelvic exam without speculum or bimanual exam
unless clinically indicated, have a screening test for bacterial vaginosis, yeast, and
trichomonas, and have a repeat pregnancy test. Subjects will also provide urine and vaginal
fluid specimens as in Visit 1. Subjects will then be randomized to LACTIN-V or placebo.
Subjects will place the first suppository under supervision and will be instructed to use a
7-day study calendar to record study product use and related symptoms during the first week,
and to use a 10-week study calendar to record study product use and related symptoms
thereafter.

Day 4-7 phone call: The purpose of this phone call is to assess use of the study product as
well as any associated symptoms.

Visit 3 will occur during Week 2, days 8-14 following randomization. Subjects will be asked
about study product use, adverse events, and symptoms. Subjects will undergo focused
physical and pelvic exams without speculum or bimanual exam unless clinically indicated.
Subjects will have a screening test for bacterial vaginosis and provide urine and vaginal
fluid specimens as before.

Visit 4 will occur during Week 11 and will be similar to Visit 3.

Visit 5 will occur during Week 16. The procedures for Visit 5 will be similar to those of
Visits 3 and 4. However, during this visit, subjects will undergo a complete pelvic exam
including speculum and bimanual exams and undergo a repeat pregnancy test.

9 Month telephone call: The purpose of this phone call is to assess the occurrence of
adverse events, symptoms of UTI, new UTI or other medical diagnoses,and pregnancy.

In addition to the above schedules visits, subjects will be asked to come to the research
clinic for Unscheduled Visits if they experience any adverse events or new symptoms of UTI.
During these unscheduled visits, subjects will undergo history, physical and complete pelvic
exams, screening tests for bacterial vaginosis, yeast, and trichomonas, as well as for other
sexually transmitted diseases as clinically indicated. Subjects will provide urine samples
for microscopic analysis, dipstick analysis, culture, and antibiotic susceptibility testing.
Subjects will provide vaginal fluid samples for assessment of CTV-05, lactobacillus, and E.
coli growth.

Subjects diagnosed with a Symptomatic UTI during the study will be treated with an
antibiotic. They will then be asked to return to the study clinic for a follow-up urine
culture two weeks later to confirm UTI resolution.

Laboratory procedures will include:

- wet mount slides of vaginal fluid (all Visits)

- urine dipstick testing (all Visits)

- urine pregnancy testing (Visits 1, 2, and 5)

- Pap smear (Visit 1)

- Testing for gonorrhea and chlamydia by culture (Visit 1, other visits as indicated)

- urinalysis (all Visits)

- urine culture (all Visits)

- gram stain and culture of vaginal fluid specimens (All Visits)

- Rep-PCR for CTV-05 (Visits 2-5)

- DNA amplification of vaginal flora (all Visits)

Statistical Analysis: The primary cohort for analysis will be the intent-to-treat (ITT)
cohort. The ITT cohort is defined as subjects who are randomized in the study. Other cohorts
to be evaluated will include the modified ITT, Evaluable, and according-to-protocol cohorts.

Inclusion Criteria:

- pre-menopausal woman aged 18-40 years

- current symptomatic uncomplicated cystitis

- cystitis is treated with trimethoprim-sulfamethoxazole (TMP-SMX)

- completion of screening procedures

- negative screening monolayer Pap smear or hysterectomy

- history of at least two prior symptomatic UTI's treated within the past 12 months or
one pior symptomatic UTI treated in the past six months

- agree to return for the Randomization Visit (Visit 2)

- regular menstrual cycles or amenorrheic due to use of a long acting progestin,
continuous use of oral contraceptives or hysterectomy

- willing to insert vaginal capsules without an applicator

- capable of providing informed consent

- able to read and understand English

- agree to abstain from self-medication with antibiotics for UTI symptoms

- agree to abstain from antibiotic prophylaxis for recurrent UTI

- agree to abstain from the use of any other intra-vaginal product

- agree to abstain from sexual intercourse for 24 hours after capsule insertion

- agree to not use tampons for 24 hours after capsule insertion

- agree to use an adequate method of birth control

Exclusion Criteria:

- complicated cystitis or uncomplicated pyelonephritis.

- cystitis at Visit 1 not treated with TMP-SMX

- uropathogen resistant to TMP-SMX isolated at Visit 1 and persistent symptoms at Visit
2 or failure to achieve a significant reduction in urine wbc count at Visit 2

- vaginal or cervical infection, currently or within the past 21 days, with bacterial
vaginosis (treated, symptomatic infection), Trichomonas vaginalis, Neisseria
gonorrhoeae, Chlamydia trachomatis or Herpes Simplex

- symptomatic bacterial vaginosis at Visit 1

- high risk for sexually transmitted diseases and/or HIV, including:

1. diagnosis of N. gonorrhoeae, C. trachomatis or T. vaginalis on two or more
occasions during the previous six months;

2. sexual intercourse with a homosexual/bisexual male in the last 10 years;

3. sexual intercourse with an injection drug user or sex worker in the last 10
years; or

4. shared needles for injected drugs in the last 10 years.

- chronic vaginal, urinary or pelvic symptoms not attributable to UTI

- recurrent bacterial vaginosis (three or more symptomatic, treated infections in the
prior 12 months)

- pregnancy or within two months of last pregnancy

- lactation

- antibiotic therapy fewer than three days prior to Randomization Visit

- antifungal therapy fewer than seven days prior to the Randomization Visit

- Antibiotics planned within four months

- abnormal Pap smear requiring a procedure for diagnosis or treatment in the past 12
months

- use of CTV-05 within one year of the Randomization Visit

- menopause

- use of a NuvaRing planned during the course of the study

- any significant disease or acute illness that in the Investigator's assessment could
complicate the evaluation

- known HIV infection

- immunosuppressive drug within 60 days

- known allergy to any component of LACTIN-V or the placebo capsule

- unavailable for follow-up visits

- drug or alcohol abuse within past two years

- any social or medical condition that, in the opinion of the Investigator, would
preclude provision of informed consent, make participation in the study unsafe,
complicate interpretation of study outcome data, or otherwise interfere with
achieving the study objectives