Lactobacillus Probiotic for Prevention of UTI
Phase: PHASE2
Conditions: Urinary Tract Infections (UTI's)
Sponsor: University of Washington

Protocol No. UW/LB-002 
 
LACTIN-V 
Original Protocol 
CONFIDENTIAL 
 
 
Lactobacillus Probiotic for Prevention of Recurrent UTI  
 
Short Title: Probiotic Phase 3 Study 
Investigational Product: 
LACTIN-V 
 
Protocol No.:  
 
UW/LB-002 
 
Original Protocol: 
 
June 9, 2005 
 
Current Protocol: 
 
February 22, 2015 
 
Study Sponsor:  
 
Ann E. Stapleton, M.D. 
 
Principal Investigator: 
Ann E. Stapleton, M.D. 
 
Study Site: 
 
 
Hall Health Primary Care Center 
University of Washington 
Seattle, Washington 98195 
Phone: 206-616-4121 
Fax: 206-616-3892 
 
 
 
 
Medical Advisor: 
 
Ann E. Stapleton, M.D. 
 
 
 
Medical Monitor: 
 
Jeanne Marazzo, M. D. 
 
 
Clinical Program Manager: 
Niki DeShaw 
 
Scientific Collaborators: 
National Institute of Digestive Diseases  
Diabetes and Kidney Diseases (NIDDK) 
 
This document is confidential.  The information contained herein may be provided only to 
the investigators, co-/sub-investigators, appropriate study personnel and the members of 
the Institutional Review Board/Research Ethics Committee to which it will be submitted.  
This protocol may not be photocopied or discussed with anyone, except the subjects to be 
selected, without prior authorization from A. Stapleton, MD. 

Protocol No. UW/LB-002 
 
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INVESTIGATOR'S SIGNATURE PAGE 
 
I have read the attached protocol entitled, “Lactobacillus Probiotic for Prevention of 
Recurrent UTI” dated 1/14/15, and agree to conduct the study according to the 
provisions described therein. 
 
I agree to comply with the International Conference on Harmonization Guideline on 
Good Clinical Practice and applicable FDA regulations set forth in 21 CFR Parts 50, 54 
and 312. 
 
I agree to ensure that the confidential information contained in this document will not 
be used for any purpose other than the evaluation or conduct of the clinical 
investigation without the prior consent of Ann Stapleton, M.D. 
 
_______________________________________________ 
[Investigator Name]  
 
 
Date 
 
 
 

Protocol No. UW/LB-002 
 
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GLOSSARY OF TERMS 
 
Abbreviation  
Definition  
 
AE 
 
 
adverse event 
ATP 
 
 
according-to-protocol 
BV 
 
 
bacterial vaginosis 
C. trachomatis  
Chlamydia trachomatis 
CDC 
 
 
Centers for Disease Control and Prevention 
CFR 
 
 
Code of Federal Regulations 
CFU 
 
 
colony forming units 
CMH  
 
Cochran-Mantel-Haenszel 
CRA  
 
 
Clinical Research Associate  
CRF 
 
 
case report form 
CTV-05 
 
the LACTIN-V strain of Lactobacillus crispatus 
DNA 
 
 
deoxyribonucleic acid 
E. coli  
 
Escherichia coli 
Eval 
 
 
evaluable 
FDA 
 
 
Food and Drug Administration 
g 
 
 
gram 
GC 
 
 
gonorrhea 
GCP  
 
 
good clinical practices 
H2O2 
 
 
hydrogen peroxide 
HIPAA  
 
Health Insurance Portability and Accountability Act 
HIV 
 
 
Human Immunodeficiency Virus 
ICF 
 
 
informed consent form 
ID 
 
 
identification 
IND 
 
 
Investigational New Drug 
IRB  
 
 
Institutional Review Board  
ITT 
 
 
intent-to-treat

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IUD 
 
 
intrauterine device 
KOH 
 
 
potassium hydroxide 
L. crispatus 
 
Lactobacillus crispatus 
L. jensenii 
 
Lactobacillus jensenii 
LMP 
 
 
last menstrual period 
MedDRA 
 
Medical Dictionary for Regulatory Activities 
mg 
 
 
milligrams 
MMWR 
 
Morbidity and Mortality Weekly Report 
N. gonorrhoeae 
Neisseria gonorrhoeae 
NIH 
 
 
National Institutes of Health 
OTC 
 
 
over-the-counter 
Pap smear 
 
Papanicolaou smear 
PCR 
 
 
polymerase chain reaction 
rep-PCR 
 
repetitive sequence polymerase chain reaction 
rUTI 
 
 
recurrent urinary tract infection 
SAE 
 
 
serious adverse event 
SD 
 
 
standard deviation 
spp. 
 
 
species 
Subject ID 
 
subject identification number 
STD 
 
 
sexually transmitted disease 
T. vaginalis 
 
Trichomonas vaginalis 
UTI 
 
 
urinary tract infection 
WHO  
 
World Health Organization 
 

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TABLE OF CONTENTS 
 
1 
STUDY SITE INFORMATION AND PERSONNEL ......................................................... 1 
1.1 
Site Names and Locations .......................................................................................... 1 
1.2 
Principal Investigator ................................................................................................. 1 
1.3 
Medical Advisor ......................................................................................................... 1 
1.4 
Medical Monitor ........................................................................................................ 1 
1.5 
Clinical Program Manager .......................................................................................... 1 
2 
 BACKGROUND AND RATIONALE ............................................................................ 2 
2.1  
Background information on Recurrent Urinary Tract Infection (rUTI) ........................ 2 
2.2 
History of product development ................................................................................ 3 
2.2.1  
Pre-clinical research .................................................................................................. 3 
2.2.2 
Clinical research ......................................................................................................... 3 
2.2.2.1  Lactin-Vaginal ........................................................................................................... 3 
2.2.2.2  
LACTIN-V ................................................................................................................ 4 
2.3 
Proposed next step ................................................................................................... 12 
3 
STUDY PURPOSE, OBJECTIVES AND ENDPOINTS ................................................... 12 
3.1 
Purpose .................................................................................................................... 12 
3.2 
Study Objectives ....................................................................................................... 12 
3.2.1 
Primary Objective .................................................................................................... 12 
3.2.2 
Secondary Objectives .............................................................................................. 12 
3.3 
Case Definitions ........................................................................................................ 13 
3.3.1 
Symptomatic UTI ..................................................................................................... 13 
3.3.2 
Probable UTI ............................................................................................................ 13 
3.3.3 
Recurrent UTI .......................................................................................................... 13 
3.4 
Study Endpoints ........................................................................................................ 13 
3.4.1 
Primary Endpoint ..................................................................................................... 13 
3.4.2 
Secondary Endpoints ............................................................................................... 13 
4 
RATIONALE .......................................................................................................... 14 
4.1 
Overview .................................................................................................................. 14 
4.2 
Rationale for Dose and Regimen ............................................................................... 14 
4.3 
Rationale for Study Design ........................................................................................ 14 
4.4 
Rationale for Study Endpoints ................................................................................... 15 
4.4.1 
Efficacy .................................................................................................................... 15 
4.4.2 
Safety ....................................................................................................................... 15 
4.4.3  
Lactobacillus Colonization ...................................................................................... 15 
4.4.4 
E. coli Colonization .................................................................................................. 16 
5 
STUDY DESIGN ..................................................................................................... 16 
5.1 
Description of the Study ........................................................................................... 16 
5.2 
Reduction of Bias ...................................................................................................... 18 
6 
STUDY MATERIALS AND METHODS ...................................................................... 18 
6.1 
Study Materials ......................................................................................................... 18 
6.1.1 
LACTIN-V and Placebo Applicators .......................................................................... 18 
6.1.2 
LACTIN-V .................................................................................................................. 18 

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6.1.2.1 
Background ........................................................................................................... 18 
6.1.2.2 
The Product .......................................................................................................... 19 
6.1.2.3 
Manufacturing and Packaging Information .......................................................... 19 
6.2 
Study Methods ......................................................................................................... 19 
6.2.1 
Subject Selection ..................................................................................................... 19 
6.2.1.1 
Recruitment .......................................................................................................... 19 
6.2.1.2 
Eligibility ............................................................................................................... 19 
6.2.1.2.1  
Inclusion Criteria ............................................................................................... 19 
6.2.1.2.2  
Exclusion Criteria .............................................................................................. 20 
6.2.1.3  
Screening Failures and Subject Replacement ...................................................... 22 
6.2.1.4 
Withdrawal of Randomized Subjects ................................................................... 22 
6.2.1.5 
Discontinuation and Subject Replacement .......................................................... 23 
6.2.2 
Blinding and Unblinding of Treatment Assignment ................................................. 23 
6.2.2.1 
Blinding ................................................................................................................. 23 
6.2.2.2 
Unblinding ............................................................................................................ 24 
6.2.2.3 
Unblinding Procedure ........................................................................................... 24 
6.3 
General Procedures .................................................................................................. 24 
6.3.1 
Informed Consent .................................................................................................... 24 
6.3.2 
Confidentiality of Records ....................................................................................... 25 
6.3.3 
Visit 0 ....................................................................................................................... 25 
6.3.4 
Visit 1 ....................................................................................................................... 26 
6.3.5 
Visits 2 thru 5 ........................................................................................................... 27 
6.3.6 
Additional Unscheduled Visits ................................................................................. 27 
6.3.7 
UTI Episodes While On Study .................................................................................. 28 
6.4 
Clinical Procedures/Evaluations ................................................................................ 28 
6.4.1 
Pelvic Examinations ................................................................................................. 28 
6.4.2 
Investigational Product Instructions ........................................................................ 29 
6.5 
Early Discontinuations .............................................................................................. 29 
6.6 
Missed Applicators ................................................................................................... 29 
6.7 
Lost Applicators ........................................................................................................ 29 
6.8 
Antibiotic Use While On Study .................................................................................. 30 
6.9 
Laboratory Procedures .............................................................................................. 30 
6.9.1 
Specimen Collection and Processing ....................................................................... 30 
6.9.2 
Laboratory Testing ................................................................................................... 30 
6.9.3 
Compliance Monitoring ........................................................................................... 31 
7 
MANAGEMENT OF ADVERSE AND OTHER EVENTS ............................................... 31 
7.1 
 Adverse Events ........................................................................................................ 31 
7.1.1  
Adverse Event Recording ........................................................................................ 31 
7.1.2  
Adverse Event Grading ........................................................................................... 31 
7.1.3  
Assessment of Causality ......................................................................................... 32 
7.2  
Serious Adverse Events ............................................................................................ 33 
7.3  
Unexpected Adverse Events ..................................................................................... 34 
7.4  
Serious Adverse Event Reporting .............................................................................. 34 
7.5  
Regulatory Reporting of Serious Adverse Events ...................................................... 34 
7.6  
Unblinding of Study Treatment Assignment ............................................................. 34 
7.7  
Pregnancy ................................................................................................................ 35 
8   
GENERAL ADMINISTRATIVE PROCEDURES .......................................................... 35 

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8.1 
Protocol Modifications .............................................................................................. 35 
8.2  
Clinical Monitoring ................................................................................................... 35 
8.3 
Individual Stopping Rules .......................................................................................... 35 
8.4 
Study Suspension or Termination .............................................................................. 35 
8.5 
Roles and Responsibilities of the Study Site .............................................................. 35 
8.6 
Protocol Deviations ................................................................................................... 36 
9 
DATA MANAGEMENT .......................................................................................... 37 
9.1 
Data Collection and Entry .......................................................................................... 37 
10 
STATISTICAL CONSIDERATIONS .......................................................................... 37 
10.1 
Primary Endpoint .................................................................................................... 37 
10.2 
Secondary Endpoints .............................................................................................. 38 
10.3 
Measurement ......................................................................................................... 38 
10.4 
Statistical Power and Sample Size Justification ....................................................... 39 
10.5 
Study Instruments .................................................................................................. 39 
10.6 
Randomization ....................................................................................................... 39 
10.7 
Cohorts for Analyses ............................................................................................... 40 
10.8 
Analysis Methods ................................................................................................... 40 
Table 1 
   Analysis Variables and Methods ....................................................................... 41 
10.9 
Analysis of Primary Endpoint .................................................................................. 42 
10.9.1 
Recurrence Rate of UTI ......................................................................................... 42 
10.9.2 
Incidence of Symptomatic UTI episodes ............................................................... 42 
10.9.3 
Time to Recurrence of the first Symptomatic/Probable UTI episode ................... 42 
10.10 
Analysis of Secondary Endpoints .......................................................................... 43 
10.10.1 
Shifts in Vaginal Microbiota, as Assessed by Nugent score ................................ 43 
Table 2   
   Nugent Score Shift Table ................................................................................ 43 
10.10.2 
Vaginal Colonization with Lactobacilli ................................................................. 43 
10.10.3 
  E. coli Vaginal Colonization ................................................................................ 44 
10.10.4 
Change in Vaginal Microbiota, as assessed by DNA amplification. ..................... 44 
10.10 5 
Safety and Tolerability. ....................................................................................... 44 
10.10.6 
Subject Characteristics and Disposition .............................................................. 44 
10.10.7 
Assessment of Protocol Compliance ................................................................... 44 
11  
RISKS AND DISCOMFORTS TO STUDY SUBJECTS ................................................ 45 
11.1  
LACTIN-V and Placebo Applicator Users ................................................................. 45 
11.1.1 
Risks ....................................................................................................................... 45 
11.1.2 
Benefits ................................................................................................................. 45 
11.1.3 
Procedures for Minimizing Potential Risks ............................................................ 45 
11.1.4 
Compare Potential Benefits with Potential Risks .................................................. 46 
11.1.5 
Costs and Compensation ....................................................................................... 46 
12 
REFERENCES ...................................................................................................... 46 
STUDY PROCEDURES FLOW CHART ............................................................................ 48 
APPENDICES .............................................................................................................. 50 
Appendix A  
Nugent Scoring System for Gram Stained Vaginal Smears .......................... 50 
Appendix B 
 Instructions ............................................................................................... 50 
Appendix C 
Diary ........................................................................................................... 50 

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Appendix A ................................................................................................................ 51 
Nugent Scoring System for Gram Stained Vaginal Smears ................................................... 51 
Appendix B ................................................................................................................ 52 
Study Diary Instructions ..................................................................................................... 52 
Appendix C ................................................................................................................ 53 
Study Diary: see attached ................................................................................................... 53 

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1 
STUDY SITE INFORMATION AND PERSONNEL 
1.1 
Site Names and Locations 
This study will be conducted at Hall Health Primary Care Center at the 
University of Washington, Seattle, Washington by the following Clinical 
Investigators: 
 
Ann Stapleton, M.D. 
Professor of Medicine 
University of Washington  
School of Medicine 
BB-1233 Health Sciences Center 
Box 356423 Seattle, WA 98195-6523 
 
1.2 
Principal Investigator  
Ann Stapleton, M.D. 
Professor of Medicine 
University of Washington School of Medicine 
BB-1233, Health Sciences Center 
Box 356423 
Seattle, WA 98125-6523 
 
1.3 
Medical Advisor 
Ann Stapleton, MD 
Professor of Medicine 
University of Washington School of Medicine 
 
1.4 
Medical Monitor 
 
       Jeanne Marazzo, MD 
Professor of Medicine 
University of Washington School of Medicine 
1.5 
Clinical Program Manager: 
Niki DeShaw 
Hall Health Primary Care Center 
University of Washington 
Box 354410 
Seattle, Washington 98195 

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2 
 
BACKGROUND AND RATIONALE  
2.1  
Background information on Recurrent Urinary Tract Infection (rUTI) 
 
Urinary tract infection (UTI) is a very common outpatient diagnosis among healthy 
young women, resulting in considerable morbidity and health care costs.  In 1997, UTI 
accounted for approximately 11 million doctor visits.  Approximately 33% of these 
women experience two or more UTIs per year.  A recent population survey of women in 
the United States found that the lifetime risk of UTI was over 60% and that the 
estimated societal cost of UTIs exceeds 25 billion dollars over 20 years (1).  To date, the 
only effective method of reducing the high risk of UTI in pre-menopausal women with a 
history of recurrent urinary tract infection (RUTI) is antimicrobial prophylaxis, a strategy 
that is becoming less effective as antimicrobial resistance amongst uropathogens 
increases (2).  In addition, antibiotic resistance, even among community-acquired UTIs, 
is making treatment of these infections more problematic (3).     
 
Thus, novel, safe and effective non-antimicrobial prevention strategies are urgently 
needed.  One such approach, for which there is strong evidence at the mechanistic level, 
is use of an H2O2-producing Lactobacillus to restore the normal vaginal microbiota (4).  If 
effective in reducing E. coli colonization and UTI, this strategy would reduce the costs 
and morbidity associated with urinary tract infections, including time lost from work, 
health care costs, antimicrobial use, and the ultimate development of antimicrobial 
resistance.  
  
Many studies have confirmed that the critical event preceding a UTI is colonization of 
the vaginal introitus with gut microbiota, most commonly E. coli (5, 6).  Women with 
recurrent UTI are more likely to be vaginally colonized with E. coli or other 
Enterobacteriaceae than women without recurrent UTI, and demonstrate prolonged 
periods of persistent colonization.  Recent studies have verified these findings and have 
demonstrated a coincident loss of the normally predominant vaginal lactobacilli [10, 11, 
12].  In a study in women of reproductive age, 15% of 302 women who had vaginal 
colonization with L. crispatus or L. jensenii, both H2O2 producers, were colonized with E. 
coli as compared with 27% of women who did not have these lactobacilli species 
present (p = 0.01) (7).  This and other data suggest that H2O2-producing lactobacilli may 
have an important role in the maintenance of the normal vaginal ecology and in the 
prevention of vaginal colonization with E. coli and thus E. coli-induced UTI. 
 
Mechanistic studies also support the ability of H2O2-producing lactobacilli to exclude E. 
coli vaginal colonization.  Thus, Osset and colleagues showed that such lactobacilli are 
capable of competitive exclusion, blocking adherence of E coli to vaginal epithelial cells 
(8).  In addition, L. crispatus inhibits the growth of E. coli in both liquid and solid media 
through the action of H2O2.  Finally, recent studies at the University of Washington have 

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shown that L. crispatus adheres extremely well to vaginal epithelial cells from women 
with recurrent UTI, suggesting it will colonize such women’s vaginal epithelium (9).   
 
2.2 
History of product development  
2.2.1  
Pre-clinical research 
 
In 1987, research conducted by Giorgi et al. suggested that the most common 
Lactobacillus in the human vagina is not Lactobacillus acidophilus, but rather 
Lactobacillus crispatus, Lactobacillus jensenii  and  Lactobacillus gasseri (10).  
Additional studies performed in the laboratories of Sharon Hillier, PhD at the University 
of Pittsburgh confirmed that Lactobacillus crispatus is the predominant H2O2-
producing Lactobacillus found in the vagina of a healthy woman (7). 
 
LACTIN-V, the product under investigation in this Phase 3 study, contains Lactobacillus 
crispatus CTV-05 bacteria preserved by spray drying with a simple drying medium.  The 
product is prepared as a powder in an applicator for intravaginal use.  Lactobacillus 
crispatus is a naturally occurring organism isolated from the vagina of a healthy woman 
in 1993.  Using repetitive sequence polymerase chain reaction (rep-PCR) DNA 
fingerprinting, investigators distinguished L. crispatus CTV-05 from other Lactobacillus 
strains derived from the human vagina.  Additionally, it was demonstrated that this 
strain produces high levels of lactic acid and H2O2 (11).   
 
Osel, Inc. plans to develop LACTIN-V for the following indications: 
 
1. To reduce the recurrence rate of urinary tract infection in women with 
recurrent uncomplicated UTI (RUTI), including acute, uncomplicated cystitis 
and pyelonephritis. 
 
2. To reduce the recurrence rate of bacterial vaginosis (BV) in women with 
recurrent BV. 
2.2.2 
Clinical research 
2.2.2.1  Lactin-Vaginal 
 
The first product containing L. crispatus CTV-05, Lactin-Vaginal, was under 
development by The Medicines Company and subject to an IND sponsored by the NIH 
(BB-IND 6603).  In previous clinical studies (three non-IND and two IND) conducted 
between 1991 and 2000, a total of 304 women received Lactin-Vaginal and were 
considered evaluable.  Although the overall results of the Phase II/III study with 
Lactin-Vaginal indicated no significant improvement in the cure rate for BV when 
Lactin-Vaginal was administered with a single 2 gram dose of metronidazole, the 

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subset of subjects who received Lactin-Vaginal and were colonized with Lactobacillus 
crispatus CTV-05 had a significantly higher clinical cure rate at 30 days than those who 
were not colonized. 
 
In this Phase II/III study, Lactin-Vaginal was shown to be safe. Adverse events that 
were reported in the phase II/III study of Lactin-Vaginal (Protocol No. 99-033) were 
equally distributed between the Lactin-Vaginal and placebo control substance groups, 
and thus were unlikely related to the L. crispatus CTV-05, with the exception of 
increased vaginal discharge while using the capsules.  All 355 women received a 
single 2 gram oral dose of metronidazole and then were randomized to either Lactin-
Vaginal or a control vaginal capsule.  Adverse events reported in at least 10% of 
subjects in this study were abdominal pain, nausea, upper respiratory infections, 
urinary tract infections, bacterial vaginitis, yeast vaginitis, back pain, urinary frequency, 
genital pruritus, intermenstrual bleeding, menorrhagia and vaginal discharge. Other 
less commonly occurring AEs reported included  dysuria,  urinary  urgency,  nocturia,  
dysmenorrhea,  vaginal  burning and/or pain, genital burning, genital erythema, genital 
edema, genital lesions, vaginal odor, diarrhea, constipation, dyspareunia, and skin 
rash.  The following Serious Adverse Events were reported in subjects who received 
Lactin-Vaginal, but all were considered unrelated to treatment: a spontaneous 
abortion which occurred 69 days after randomization; a ruptured ectopic pregnancy 
which occurred 79 days after randomization; and a gall bladder removal 92 days after 
randomization. 
 
Osel, Inc. has acquired the commercialization rights for this product and also the 
manufacturing facilities used to produce Lactin-Vaginal. Osel, Inc. planned to develop 
the product for the following indications: 
 
1.  To reduce the recurrence rate of BV. 
 
2.  To reduce the recurrence rate of urinary tract infections in women with 
recurrent uncomplicated UTI (RUTI) 
 
2.2.2.2  
LACTIN-V 
Two rounds of important modifications have been made to the original Lactin - 
Vaginal product by The Medicines Company. The new product developed by 
Osel, Inc. was called LACTIN-V. 
 
The first formulation of LACTIN-V (Formulation 1) incorporated the following changes 
into the manufacturing process and was used in the trials LV 001 – LV004: 
 
o Preparation of a new Master Cell Bank; 
 
o Reformulation to reduce the quantity of fermentable sugars in the final study 
product; this reformulation has resulted in a more potent study product; 
 

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o Replacement of the fermentation medium with an animal by-product-free 
medium; 
 
o Changes in the fermentation process leading to the harvest of bacteria in a 
“log growth phase” versus “stationary growth phase”; 
 
o Increase in the number of viable bacteria per capsule; 
 
o Reduction in the size of gelatin capsules 
 
o Reduction in the volume of the capsule 
 
LACTIN-V (Formulation 1) contains Lactobacillus crispatus CTV-05 bacteria preserved as 
a dry powder.  Using repetitive sequence polymerase chain reaction (rep-PCR) DNA 
fingerprinting, investigators distinguished L. crispatus CTV-05 from other Lactobacillus 
strains derived from the human vagina.  Additionally, it was demonstrated that this 
strain produces high levels of lactic acid and H2O2 (11).   
 
LACTIN-V (Formulation 1) has been tested in several phase I and phase II 
studies: 
 
LACTIN-V Study LV-001  
 
Osel, Inc. completed an initial Phase I study of LACTIN-V (Formulation 1) in healthy 
pre-menopausal women (Study No. LV-001) under BB-IND 11363. In LV-001, 60 
women were randomized (1:1:1:1) between four groups: low dose LACTIN-V at 5 x 
106 cfu/capsule; high dose LACTIN-V at 5 x 108 cfu/capsule; control capsule; and 
untreated.    Commencing at Visit 1 (Day 1), all capsule recipients inserted one capsule 
daily for five consecutive days and returned to the clinic for two follow-up visits (Visit 
2 between Days 6–8 and Visit 3 between Days 26–34).   Safety was evaluated by 
symptoms, pelvic examinations, colposcopy and urinalyses.  Colonization and shifts in 
other vaginal microbiota were assessed at Day 7 (+/-1) and at Day 30 (+/-4).  
Colonization data indicates that approximately twice as many subjects in the LACTIN-V 
5 x 108 cfu/capsule dose arm (approximately 40% colonization rate) versus the LACTIN-
V 5 x 106 cfu/capsule dose cohort (approximately 20% colonization rate) were 
successfully colonized with L. crispatus strain CTV-05 at Day 30. 
 
No serious adverse events were reported in Protocol No. LV-001, and no subject left the 
protocol due to an adverse event. Long-term safety was assessed by a telephone follow-
up at Month 6.  Most AEs were mild to moderate.  No single severe AE was experienced 
by more than one subject.  Three subjects each experienced a single severe, treatment-
related AE: abdominal pain, vaginal candidiasis, vaginal burning sensation, vaginal 
hemorrhage and vaginal irritation. There were no notable, unexpected AEs, no SAEs and 
no deaths.  No subject left the study due to an AE. The most frequent (≥10%) non-
gynecologic AEs reported regardless of causality were abdominal pain NOS (25.0%), 
headache NOS (23.3%) and diarrhea NOS (10.0%).  The most frequent (≥10%) 
gynecologic AEs reported were vaginal discharge (35.0%), genital pruritis female 

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(26.7%), vaginal hemorrhage and vaginal odor  (15.0%, each), and vaginal burning 
sensation and vaginal candidiasis (11.7%, each).  Forty (88.9%) of subjects participating 
in this study experienced an AE that was considered by the Investigator to be possibly 
or probably related to study treatment (LACTIN-V or control capsule).  The most 
common (≥10%) non-gynecologic AEs reported as possibly or probably related to study 
treatment were abdominal pain NOS (22.2%), headache NOS (17.8%) and diarrhea 
NOS and vaginal candidiasis (11.1%, each).  The most common (≥10%) gynecologic AEs 
that were reported by the Investigator as possibly or probably related to study 
treatment were vaginal discharge  (46.7%), genital pruritis female (31.1%), vaginal 
odour (20.0%), vaginal hemorrhage (17.8%) and vaginal burning sensation (15.6%). 
 
Results obtained indicate that LACTIN-V is safe and well tolerated when administered 
to healthy subjects once a day for five days at either 5 x 10 6 cfu/capsule or 5 x 108 
cfu/capsule. The safety and vaginal microbiota changes in the placebo control group 
demonstrated that it was a valid comparison group for use in future studies, instead of 
using an untreated group.  
 
LACTIN-V Study LV-002 
 
Osel, Inc. conducted a second Phase I study, Protocol No. LV-002, in a cohort of healthy 
pre-menopausal women with a history of uncomplicated recurrent UTI. The design of 
this study was similar to Protocol No. LV-001 with the exception that there were 30 
women randomized (1:1) to receive either LACTIN-V Formulation 1 (5 x 108 
cfu/capsule) or the control capsule once daily for five days.  Safety was evaluated by 
symptoms, urinalyses and pelvic examination. Colonization was assessed at Day 7 (+/-
1) and at Day 30 (+/-4), in addition to shifts in other vaginal microbiota.   Long-
term safety was assessed by a telephone follow-up at Month 6. In general, the study 
product was well tolerated.  
 
A high rate of positive L. crispatus strain CTV-05 assays at study baseline in the 
Evaluable Cohort (33.3% and 7.7% in the LACTIN-V and the control capsule groups, 
respectively) may have been due to a lack of specificity of the assay.  The CTV-05 rep-
PCR assay, which was still under development at the time, may have lacked sufficient 
specificity in this study to distinguish between endogenous, H2O2-producing L. 
crispatus and the CTV-05 (LACTIN-V) strain of L. crispatus. The CTV-05 colonization 
rates observed in subjects receiving LACTIN-V in this study (40.0% at Visit 2 and Visit 3) 
were lower than anticipated, possibly due to the high rate of endogenous lactobacilli at 
baseline in this population of healthy pre-menopausal women.  All study subjects in 
the Evaluable Cohort were vaginally colonized with H2O2-producing lactobacilli at study 
entry, and they remained colonized throughout the study.  It was anticipated that in 
women with disrupted vaginal microbiota and reduced lactobacilli following antibiotic 
treatment of recurrent BV or RUTI, the CTV-05 colonization rates would be higher. 
 
In Protocol No. LV-002, LACTIN-V appeared to be safe and well tolerated when 
administered intravaginally for five consecutive days at a dose of 5 x 108 cfu/capsule.  

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All AEs were mild to moderate; no severe or severe, related AEs were reported.  
There were no notable, unexpected AEs, no SAEs and no deaths. No subject left the 
study due to an AE.   Fourteen subjects in the LACTIN-V group reported a total of 37 
events.  In the control group, 14 subjects reported a total of 41 events.  Overall, the 
most frequent (≥10%) non-gynecologic AEs reported regardless of causality were 
headache NOS (43.3%), abdominal pain NOS (23.3%) and back pain (13.3%).  The 
most frequent (≥10%) gynecologic AEs reported were vaginal discharge (43.3%), female 
genital pruritis (13.3%), vaginal candidiasis (13.3%) and dysmenorrhea (10.0%).  
Twenty-two (73.3%) of the 30 subjects participating in this study experienced an AE 
that was considered by the Investigator to be possibly or probably related to study 
treatment (10 subjects in the LACTIN-V group, 12 subjects in the control group).  The 
most common (≥10%) AEs that were reported by the Investigator as possibly or 
probably related to study treatment  were  vaginal  discharge  (43.3%),  female genital 
pruritis (13.3%) and vaginal candidiasis (13.3%).  Six subjects in the LACTIN-V group 
reported a total of six  events  that  were  considered to  be possibly related to study 
treatment, five subjects reported six event s that were probably related, and one 
subject reported an event that was considered by the Investigator to be related to 
study treatment (mild vaginal discharge).  In the control group, eight subjects reported 
a total of eleven events that were considered to be possibly related to study drug, six 
subjects reported six events that were probably related, and one subject reported an 
event that was considered to be related to study treatment  (moderate vaginal 
discharge).    None of the AEs reported were considered to be severe. Five subjects in 
the LACTIN-V group reported eight events that were considered to be moderate.  All 
of these events were considered unrelated to study treatment, with the exception of a 
single occurrence of vaginal candidiasis, which was considered to be possibly related. 
Five subjects in the control group reported a total of eight moderate AEs. Long-term 
safety was assessed by a telephone follow-up at Month 6. The study was published in 
2007 (12)  
 
 
LACTIN-V Study LV-003 
 
In 2005-2006, Osel Inc. conducted a Phase II, randomized, double-blind, placebo- 
controlled, multi-center study to assess safety, colonization rate and efficacy of 
preventing recurrence of bacterial vaginosis (BV).  The study was conducted in 149 
women with a history of recurrent BV who had recently been treated with a course of 
intravaginal metronidazole or clindamycin.   Following completion of the prescribed 
course of antibiotic, each subject was randomized (1:1) at Visit 2 (Day 1) to receive 
either one LACTIN-V (Formulation 1) capsule at a dose of 5 x 108  colony forming units 
(cfu) per capsule daily for five days followed by one capsule per week for 10 weeks 
or the placebo capsule on the same schedule.  Of those subjects who had 
Lactobacillus culture results, the percentage of subjects who were colonized with the 
L. crispatus, CTV-05 strain was significantly greater in the LACTIN-V group compared 
to the placebo group for both the modified intent-to-treat (MITT) and according-to-

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protocol (ATP) cohorts [41.7% vs. 6.2%, respectively, in the MITT cohort (p=0.0000) 
and 59.3% vs. 12.1%, respectively, in the ATP cohort (p=0.0023)].   Although not 
reaching levels of statistical significance, the rate and the incidence of reported 
symptomatic BV episodes was lower in the LACTIN-V group compared to the placebo 
group (in both the MITT and ATP cohorts).  In addition, the time to first recurrence 
of symptomatic BV was longer in LACTIN-V subjects compared to placebo subjects in 
the MITT cohort (118.7 days) in the LACTIN-V group and 98.7 days in the placebo 
group. Although overall encouraging, the provided data could not fully answer the 
research question of efficacy of prevention of BV recurrence due to low sample size 
and a low colonization rate of 41.7% for the MITT cohort and 59.3% for the ATP 
cohort. 
 
For Protocol No. LV-003, 111 of 149 subjects (74.5%) reported at least one AE (76.7% 
of LACTIN-V subjects and 72.4% of placebo control substance subjects). Overall, the 
most common AEs reported  were  vaginal  discharge  (38.9%), vaginitis bacterial NOS  
(24.2%), genital pruritis female (23.5%) and  vaginal odour (22.1%). Adverse events 
were mostly mild (67.8%) or moderate (28.2%) in severity, and the majority of subjects 
had AEs that were assessed as possibly or probably related to study product (56.4%).  
No safety signal was observed for the LACTIN-V group in regard to AEs, with the 
exception of a higher rate (≥5% difference between treatment groups) of nausea, 
diarrhea, dysuria, vaginal discharge and vaginal odour.  One subject experienced three 
simultaneous SAEs (hemiparesis, blurred vision in right eye and headache); however, 
as this subject was in the placebo control substance group, the SAEs were unrelated to 
LACTIN-V.   Two subjects in the LACTIN-V group discontinued study treatment due to 
AEs; one subject became pregnant and the other reported nausea and diarrhea, 
which required treatment. No deaths were reported during this study.  
 
LACTIN-V study LV-004 
 
A conducted by Osel Inc. was planned to involve 100 women with a history of 
recurrent, uncomplicated UTIs who had recently been treated for UTI with a course of 
antibiotics.  Only subjects treated with amoxicillin/clavulanate (Augmentin), a 
quinolone or nitrofurantoin would have been eligible for enrollment. Subjects were to 
be randomized to one of two groups (50 subjects per group) to either receive one 
capsule of LACTIN-V Formulation 1 (at 5 x 108 cfu/capsule) or one placebo daily for five 
days followed by one capsule per week for 10 weeks. In addition to safety, this 
study was to evaluate the preliminary efficacy of LACTIN-V in reducing the incidence 
of symptomatic, probable and asymptomatic UTI.  Subjects were to be queried at 
each clinic visit for urinary symptoms, including dysuria, frequency, urgency, 
hematuria, flank pain or suprapubic pain.  This study was to also evaluate vaginal 
colonization with lactobacilli, Lactobacillus crispatus, strain CTV-05 and E. coli following 
administration of LACTIN-V. 
 

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The trial was halted due to logistical difficulties after only four subjects had been 
enrolled at three of the six study sites.  Due to an enrollment rate that was much 
slower than expected, even after the addition of two more study sites, Study No. LV-
004 was closed to further recruitment much in advance of reaching the target 
enrollment number of 100. Among the four subjects that completed the study and 
were being followed for long-term safety, a total of six AEs were reported during the 
study in two subjects in the LACTIN-V group.  All of the AEs were considered by the 
Investigator to be of moderate severity and unrelated to study treatment. There were 
no severe or severe related AEs. There were no notable, unexpected adverse events, 
no serious adverse events and no deaths.   
 
LACTIN V study UW/LB-001 
 
Following the problems with low enrollment described above for LV-004, a study with 
similar study design using LACTIN-V for prevention of recurrent UTI was undertaken at 
the University of Washington. In addition to safety, this study was to evaluate the 
preliminary efficacy of LACTIN-V in reducing the incidence of symptomatic, probable 
and asymptomatic UTI.  In the study UW/LB-001, 100 young healthy women with a 
history of recurrent UTI received antimicrobials for acute UTI and then were randomized 
to one of two groups (50 subjects per group) to either receive one capsule of LACTIN-V 
Formulation 1 (at 5 x 108 cfu/capsule) or one placebo daily for five days followed by one 
capsule per week for 10 weeks.  Participants were followed up at 1 week and 10 weeks 
after intervention and for UTIs; urine samples for culture and vaginal swabs for real-time 
quantitative 16S ribosomal RNA gene polymerase chain reaction for L. crispatus were 
collected.  This study was to also evaluate vaginal colonization with lactobacilli, 
Lactobacillus crispatus, and strain CTV-05 following administration of LACTIN-V.  
 
Recurrent UTI occurred in 15% (7/48) of women receiving Lactin-V compared with 27% 
(13/48) of women receiving placebo (relative risk [RR], .5; 95% confidence interval, .2–
1.2). High-level vaginal colonization with L. crispatus (>106 16S RNA gene copies per 
swab) throughout follow-up was associated with a significant reduction in recurrent UTI 
only for Lactin-V (RR for Lactin-V, .07; RR for placebo, 1.1; P < .01).  
 
Adverse effects were reported by 56% of participants who received Lactin-V and by 50% 
of participants who received placebo; the most common adverse effects included 
vaginal discharge or itching or moderate abdominal discomfort. One participant in the 
placebo group discontinued treatment because of adverse effects. The incidence of BV 
or candidal vaginitis was low in both treatment groups (0%–5%), and there was no 
significant difference in rates of pyuria between the 2 groups (rate at visit 3 among 
women in the Lactin-V group, 13%; rate at visit 3 among women in the placebo group, 
22%; rate at visit 4 among women in the Lactin-V group, 32%; rate at visit 4 among 
women in the placebo group, 33%). No serious AEs or episodes of pyelonephritis were 
reported in either group. This study was published in 2011 and concluded that Lactin-V 
after treatment for cystitis is associated with a reduction in recurrent UTI (13).   

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LACTIN-V study LV-005 
 
As a result of the non-optimal colonization rate using LACTIN-V (Formulation 1) 
delivered in capsules, as seen in Protocols No. LV-003 and LV-004, it was recognized 
that the gelatin capsule used in the previous LACTIN-V dosage form dissolved slowly in 
the vagina, likely contributing to sub-optimal colonization of the bacteria.   To 
circumvent this problem and improve the colonization rates of L. crispatus CTV-05, a 
new round of study product and protocol improvements incorporated the following 
measures: 
• Elimination of the gelatin capsule 
• Development of a pre-filled vaginal applicator for administration of the LACTIN-V 
powder formulation directly into the vagina without a capsule (Formulation 1 in 
applicator) 
• Increasing the amount of L. crispatus CTV-05 per dose (i.e., per applicator) from 5 x 
108 (150 mg) to 2 x 109 cfu/dose (600 mg) 
• Elimination of the lag time between completion of antibiotic treatment and 
initiation of LACTIN-V dosing 
 
In late 2007 Osel commenced a small phase I dose-ranging clinical study (LV-005) to 
assess the safety, tolerability and acceptability of LACTIN -V (Formulation 1) powder 
delivered with pre-filled vaginal applicators in healthy pre-menopausal women. Study 
Protocol No. LV-005 also assessed higher doses than used in the prior LV-001 to LV-004 
studies; increasing the amount of L. crispatus CTV-05 per dose (i.e., per applicator) 
from 5 x 108 (150 mg) to 1 x 109 (300 mg) and 2 x 109 cfu/dose (600mg).  Twelve 
healthy volunteers were enrolled in 3 blocks of 4 (5 x 108, 1 x 109, and 2 x 109 cfu/dose). 
Each block was randomized in a 3:1 ratio of active product to placebo. Participants 
used study product for 5 consecutive days, returned for follow-up on days 7 and 14, 
and had phone interviews on days 2 and 35. 
 
All 12 subjects took 5 doses and completed study follow-up.  No SAEs were reported 
for Study Protocol No. LV-005. All 12 participants took 5 doses and completed study 
follow-up. Overall, 45 adverse events (AEs) occurred, of which 31 (69%) were 
genitourinary (GU) AEs. GU AEs appeared evenly distributed between the 3 treatment 
blocks and between LACTIN-V and placebo arms. The most common GU AEs were 
vaginal discharge in 5 subjects (42%), abdominal pain in 4 subjects (33%), metrorrhagia 
in 4 subjects (33%), vulvovaginitis in 4 subjects (33%), vaginal candidiasis in 3 subjects 
(25%), and vaginal odor in 3 subjects (25%). Forty-one (91%) AEs were mild (grade 1) in 
severity. All 4 moderate AEs (grade 2) were unrelated to product use. No grade 3 or 4 
AEs or serious adverse events (SAE) occurred. Laboratory parameters and colposcopy 
findings were within normal limits or clinically insignificant. The product was well 
tolerated and accepted. The study concluded that all 3 dosage levels of LACTIN-V 
appeared to be safe and acceptable in healthy volunteers.  This study was published in 
2009 (14).  

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LACTIN-V study LV-006 
 
Following the phase I clinical study LV-005, Osel, Inc. completed a phase IIa clinical 
study to further assess the colonization efficiency of L. crispatus CTV-05 in otherwise 
healthy pre-menopausal women diagnosed with BV, administered immediately after 
completion of  a  standard  antibiotic  treatment  with metronidazole (MetroGel), using 
the pre-filled vaginal applicator. In addition, safety, tolerability and acceptability of 
LACTIN-V (Formulation 1) were assessed. 
 
In this Phase IIa study, twenty-four women with BV were randomized in a 3:1 ratio of 
active product to placebo. Participants used LACTIN-V at 2 x 109 colony-forming units 
(cfu)/dose or placebo for 5 initial consecutive days, followed by a weekly application 
over 2 weeks. They returned for follow-up on Days 10 and 28.  Sixty-one percent of the 
18 women randomized to the LACTIN-V group were colonized with L. crispatus CTV-05 
at Day 10 or Day 28. Among LACTIN-V users with complete adherence to the study 
regimen, 78% were colonized at Day 10 or Day 28. Of the 120 adverse events (AEs) that 
occurred, 108 (90%) and 12 (10%) were of mild and moderate severity, respectively. AEs 
were evenly distributed between the LACTIN-V and placebo group. Of the total AEs, 93 
(78%) were genitourinary in origin. The most common genitourinary AEs included 
vaginal discharge (46%), abdominal pain (46%), dysuria (21%), pollakiuria (21%), vaginal 
odor (21%), and genital pruritus (17%). No grade 3 or 4 AEs or serious AEs occurred and 
no deep epithelial disruption was seen during colposcopic evaluation. The product was 
well tolerated and accepted. The applicator and dosage modifications resulted in a 
more potent LACTIN-V product (Formulation 1 in applicator) and an improved clinical 
protocol, leading to higher colonization and thus greater efficacy to prevent recurrent 
BV (15).  
 
In early clinical studies conducted by The Medicines Company between 1991 and 2000, 
a total of 304 women received Lactin-Vaginal and were considered evaluable.   
Although the overall results of the phase II/III study with Lactin - Vaginal indicated 
no significant improvement in the cure rate for BV when the study product was 
administered with a single 2 gram dose of metronidazole, the subset of subjects 
colonized with L. crispatus CTV-05 had a better clinical outcome.    In this study, 
Lactin-Vaginal was demonstrated to be safe, with no category of adverse events 
occurring at a statistically higher frequency in the Lactin-Vaginal group than among 
controls.  Later studies conducted by Osel, Inc. with the product LACTIN-V (Formulation 
1 in capsule) at 5 x 106 or 5 x 108 cfu/capsule (Protocol No. LV-001 through LV-004) 
included more than 200 women (half of them being exposed to LACTIN-V) and 
provided excellent data on the safety of the study product.  
 

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2.3 
Proposed next step 
The goal of the proposed studies is to test the preliminary efficacy of LACTIN-V in 
recurrent UTI, as well as to confirm previous safety data. The pre-filled vaginal 
applicator delivery system will be employed for LACTIN-V as a powder formulation of 
Lactobacillus crispatus CTV-05 provided at a dose of 600 mg (containing 2 x 109 CFU of L. 
crispatus CTV-05 per dose), as in published trials using LACTIN-V for BV (15, 16). 
 
3 
STUDY PURPOSE, OBJECTIVES AND ENDPOINTS 
3.1 
Purpose 
The purpose of this study is to evaluate the efficacy and safety of Lactobacillus crispatus 
strain CTV-05 (LACTIN-V) in pre-menopausal women with uncomplicated recurrent 
urinary tract infection (RUTI). The purpose, objectives, endpoints, and design of this 
study will be similar to the completed Phase 2 study of the safety and preliminary 
efficacy of LACTIN-V (13).  
 
3.2 
Study Objectives  
3.2.1 
Primary Objective 
The primary objective of this study is to evaluate the efficacy of LACTIN-V, compared to 
placebo, in pre-menopausal women with recurrent uncomplicated UTI.  
 
1. To evaluate the number (percent) of subjects in each treatment group with at 
least one recurrence of symptomatic UTI. 
2. To evaluate the efficacy of LACTIN-V, compared to placebo, in reducing the 
incidence of symptomatic UTI.  
3. To evaluate the time to recurrence, in subjects receiving LACTIN-V as compared 
to placebo, of symptomatic UTI 
 
3.2.2 
Secondary Objectives 
1. To evaluate vaginal colonization with total Lactobacillus (endogenous and 
exogenous) in subjects receiving LACTIN-V versus placebo.  
2. To evaluate vaginal colonization with Lactobacillus crispatus strain CTV-05 
(the LACTIN-V strain of Lactobacillus).  
3. To evaluate vaginal colonization with E. coli in subjects receiving LACTIN-V 
versus placebo. 
4. To evaluate shifts in vaginal microbiota in subjects receiving LACTIN-V versus 
placebo, as assessed by Nugent score of vaginal gram stains at all visits.  

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5. To evaluate shifts in the composition of vaginal microbiota in subjects 
receiving LACTIN-V versus placebo, as assessed by qualitative and/or 
quantitative DNA amplification of stored vaginal fluid specimens from all 
visits.  
6. To evaluate the safety of LACTIN-V over four months. 
 
3.3 
Case Definitions 
3.3.1 
Symptomatic UTI  
Symptomatic UTI is defined as an episode with one or more UTI symptoms (dysuria, 
urgency, frequency) prompting evaluation and treatment, with a positive urine culture.  
A positive urine culture is defined as ≥ 102/ml of an uropathogen in these patients.   
3.3.2 
Probable UTI 
Probable UTI is defined as an episode with one or more UTI symptoms (dysuria, urgency, 
frequency) prompting evaluation and treatment. This can occur in the absence of a MSU 
culture. 
3.3.3 
Recurrent UTI 
In this study, for the purpose of eligibility, the diagnosis of recurrent UTI is defined as one 
or more symptomatic, treated UTIs in the prior 12 months.  
 
3.4 
Study Endpoints 
3.4.1 
Primary Endpoint 
The primary endpoint of this study is to demonstrate the efficacy of Lactobacillus 
crispatus strain CTV-05 (LACTIN-V) in pre-menopausal women with RUTI, when 
administered vaginally at a dose of 2 x 109 CFU once per day for five consecutive days 
followed by once per week for 8 weeks, for preventing RUTI.  
 
3.4.2 
Secondary Endpoints 
To evaluate changes in the vaginal environment and determine the extent of 
colonization of CTV-05 over the course of the study and to assess AE’s reported by 
subjects or thru physical exam by investigators. 

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4 
RATIONALE 
4.1 
Overview 
The goal of this Phase 3 study is to obtain preliminary data on LACTIN-V’s ability to 
reduce the UTI recurrence rate, decrease UTI incidence and/or increase time to first UTI 
recurrence in pre-menopausal women who have a history of recurrent uncomplicated 
UTI, and to continue to evaluate the safety of LACTIN-V.   LACTIN-V will be administered 
at a dose of 5 x 109 CFU of L. crispatus strain CTV-05/powder applicator once daily for 
five consecutive days then once per week for the following 10 weeks. Subjects will be 
followed off LACTIN-V or placebo for an additional 10 weeks following this dosing 
regimen for recurrent UTI, vaginal microbiota measures, and AEs.  
4.2 
Rationale for Dose and Regimen 
LACTIN-V is available in a dose level of 5 x 109 CFU/applicator for this Phase 3 study in 
the rUTI population, which is the same dose studied in a Phase 1 Study and a Phase 2a 
BV study (Protocols LV-005 and LV-006, respectively).  No serious adverse events have 
been reported.  
 
Preliminary data from Protocol LV-001 have shown that subjects receiving LACTIN-V at 
the 5 x 108 CFU/capsule dose level had a 40% colonization rate (6/15 subjects) with the 
L. crispatus strain CTV-05, as compared to a 20% colonization rate (3/15 subjects) in the 
5 x 106 CFU/capsule treatment group (Osel Inc., personal communication). At a dose of 2 
x 109 CFU/applicator (Protocol LV-006), 61% of women randomized to the LACTIN-V 
group were colonized with L. crispatus CTV-05 at Day 10 or Day 28. Among LACTIN-V 
users with complete adherence to the study regimen, 78% were colonized at Day 10 or 
Day 28.   
 
The dosing regimen selected for this study was based on the dosing regimen in the 
Phase 1 and 2a studies with LACTIN-V, in which subjects inserted one capsule daily for 
five consecutive days, followed by one applicator weekly for 2 weeks.  In this Phase 3 
study, as in Protocol UW/LB-001, subjects will receive one intravaginal applicator daily 
for five consecutive days (Days 1–5), followed by one applicator weekly for 10 weeks 
(starting on Day 8) for a total of 15 applicators over 11 weeks.  Weekly dosing has been 
added for 10 weeks following the initial five-day course so that L. crispatus strain CTV-05 
colonization can be maintained throughout the study period.  
 
4.3 
Rationale for Study Design 
The study will enroll 276 pre-menopausal women currently with a symptomatic UTI who 
report at least one other symptomatic UTI episode treated within the past 12 months.  
Subjects will be randomized to receive either LACTIN-V (5 x 109 CFU/applicator) or a 
placebo applicator in a 1:1 ratio.  The Randomization Visit (Visit 1) must occur within 3–

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10 days of completing antibiotics since the vaginal microbiota is thought to be 
maximally disrupted at this time, thus providing L. crispatus CTV-05 the best chance of 
successful colonization.   
 
It is not anticipated that the entry UTI episode will necessarily have fully resolved at the 
time of randomization (Visit 1), as mild symptoms may still be present, and the dipstick 
and urinalysis may still be positive or equivocal several days after completing antibiotics.  
However, the urine culture is anticipated to be negative at Visit 1, following completion 
of antibiotics; therefore, subjects with a positive urine culture at this visit will be 
considered an antibiotic treatment failure.    
 
All subjects will return to clinic at 2, 4, 8, 12, and 16 weeks to assess efficacy and safety. 
Colonization with L. crispatus CTV-05 and other lactobacilli, as well as E. coli, will be 
assessed at all visits.  Nugent scores will be determined at baseline and all subsequent 
visits to evaluate vaginal microbiota pre- and post-treatment.  
 
4.4 
Rationale for Study Endpoints 
4.4.1 
Efficacy 
Preliminary efficacy will be assessed by evaluating subjects for Symptomatic UTI. 
Subjects will also be queried at each visit for any UTI symptoms occurring since the prior 
visit.  In addition, subjects will be instructed to return to clinic for an additional visit if 
they develop symptoms of UTI during the four-month study period. 
 
4.4.2 
Safety 
Safety will be evaluated using the following safety measures: 
1. 
Subjects will be queried about adverse events at all visits. 
2. 
Subjects will be given a Study Diary to record symptoms.   
3. 
Genital examinations at all visits. Complete pelvic exams at visit one and six or if 
clinically indicated. 
4.4.3  
Lactobacillus Colonization 
Vaginal colonization with lactobacilli will be assessed by vaginal culture.  This culture 
information will be both specific to L. crispatus CTV-05 and non-specific (total vaginal 
lactobacilli, including endogenous and exogenous lactobacilli).  
 
Total Lactobacillus colonization and H2O2 production will be assessed using culture.  
Colonization specifically with L. crispatus CTV-05 will be assessed using a DNA 
fingerprinting technique known as rep-PCR (11), a repetitive element sequence-based 
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amplifying its unique pattern of DNA fragments.  This technique, which makes use of 
repetitive sequences dispersed throughout a bacterial genome for the direct 
amplification of genomic DNA, generates bacterial species- or strain-specific fingerprint 
patterns.  Rep-PCR can be used to distinguish probiotic L. crispatus strain CTV-05 from 
other L. crispatus species.  The Lactobacillus cultures and CTV-05 rep-PCR will be 
performed in the lab of Ann Stapleton, M.D. at the University of Washington.  The rep-
PCR data collected will be used to assess the correlation between colonization and 
clinical endpoints.  
 
Vaginal fluid specimens will be stored from each visit for analysis of shifts in the 
composition of vaginal microbiota by qualitative and/or quantitative DNA amplification 
methods.  DNA amplification will be performed in the lab of Ann Stapleton M.D. at the 
University of Washington. 
4.4.4 
E. coli Colonization 
Vaginal colonization with E. coli will be assessed by vaginal culture at all visits.  The E. coli 
cultures will be performed in the lab of Ann Stapleton, M.D. at the University of 
Washington.   
5 
STUDY DESIGN 
5.1 
Description of the Study 
This is a Phase 3, randomized, double-blind, placebo-controlled study.  Safety will be 
assessed using self-reported symptoms, pelvic examinations and vaginal cultures.  The 
study will be conducted in 276 women with UTI symptoms and a history UTI in the past 
12 months. The duration of the antibiotic course prior to study entry is anticipated to be 
3–5 days¸ however the length of treatment will be decided by the treating provider. 
 
At the Screening Visit (Visit 0), subjects will be evaluated for eligibility with a medical 
history, physical examination, genital examination and vaginal swabs for specimen 
collection. 
 
If found eligible based on the results of the Screening Visit (v0), the subject will be 
prescribed antibiotics and scheduled to return for the randomization visit in 3-10 days 
after antibiotic completion. At Visit 1 subject will be randomized to receive either 
LACTIN-V at a dose of 5 x 109 CFU/applicator daily for five days followed by one 
applicator per week for 8 weeks or the placebo applicator on the same schedule.  The 
LACTIN-V applicator will contain active Lactobacillus (strain CTV-05) in maltodextrin and 
a preservation matrix and the placebo capsule will contain maltodextrin and 
preservation matrix only. LACTIN-V is supplied as a powder formulation in a pre-filled, 
single-use applicator. The preservation matrix contains xylitol, trehalose, and sodium 
ascorbate. LACTIN-V placebo applicators contain 200 mg of the powder formulation 
without L. crispatus CTV-05.  

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Visit 0 (Screening Visit) will occur at the time of the UTI diagnosis. Visit 1 should occur 
within 3–10 days of completing antibiotic. Visit 2 will occur at Week 3, Visit 3 at Week 6, 
and visits will be monthly thereafter for 3 months.  
 
At Visit 1, each subject who continues to meet all inclusion and exclusion criteria will be 
randomized and will receive a box containing 15 applicators.  Two extra applicators will 
be kept at the study site in case a lost or damaged applicator needs to be replaced. The 
first study applicator will be inserted under supervision in clinic at this visit.  The 
remaining 14 applicators will be inserted daily at bedtime on Days 2–5, and then weekly. 
Women are to abstain from sexual intercourse and tampon use for 24 hours after each 
applicator is used.  If the subject’s partner uses condoms, they will be instructed to use 
non-spermicidal condoms to avoid killing the L. crispatus.  The use of other intravaginal 
products including douching is prohibited throughout the four-month study period.  
Subjects must agree not to self-medicate with antibiotics or antifungals during the four-
month study period. However, subjects may be treated for any on-study vaginal or other 
infection if a health care provider deems such treatment necessary.  Subjects who 
receive antibiotic or antifungal treatment after commencing the study should continue 
to insert the study applicator according to their allocated schedule.   
 
Subjects will be provided with a Study Diary to use to record applicator use information 
during the study. The Study Diary will also be used by subjects to record any symptoms. 
Subjects will be instructed on how to use these memory aids to remind them to insert the 
applicator on the designated day and to record the date and time when each applicator 
was inserted.   
 
Self-reported symptoms will be evaluated at all study visits. Subjects will be queried about 
the following symptoms:  
 
 Nausea or vomiting   
 Abdominal Discomfort 
 Diarrhea 
 Constipation 
 Rash 
 Abnormal Vaginal  
     Discharge/Bleeding 
 Abnormal Vaginal Odor 
 Genital itching or burning 
 External genital irritation/swelling 
 Painful Urination   
 Urinary Frequency 
 Urinary Urgency 
 Blood in urine 

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 Headache 
 Other:_____________________ 
 
Subjects will be instructed to call the study clinic if they have any unexpected symptoms 
at any time during the study.   
 
Pelvic examinations will be performed at all visits to evaluate the external genitalia; 
cervix and vaginal mucosa for signs of irritation at Visits 1 and 6 and if clinically 
indicated.  
 
In addition to safety, this study will evaluate the efficacy of LACTIN-V in reducing the 
incidence of Symptomatic UTI.  Subjects will be queried at each clinic visit for urinary 
symptoms, including dysuria, frequency, urgency, hematuria, flank pain or suprapubic 
pain.  Urinary dipstick, urinalysis and urine culture will be performed at each clinic visit.  
Subjects will be asked to return to clinic as soon as possible if they develop symptoms of 
UTI during the four-month study period.    
 
5.2 
Reduction of Bias  
Measures proposed to limit bias include making the LACTIN-V and placebo applicators 
similar in appearance.  Both study personnel and the subject will be completely blinded 
to the random treatment assignment. 
 
6 
STUDY MATERIALS AND METHODS 
6.1 
Study Materials 
6.1.1 
LACTIN-V and Placebo Applicators 
Each LACTIN-V applicator contains 200 mg of LACTIN-V powder with 2 x 109 CFU of L. 
crispatus CTV-05. The LACTIN-V powder formulation also contains maltodextrin, xylitol, 
trehalose, and sodium ascorbate.  LACTIN-V placebo applicators contain 200 mg of the 
powder formulation without L. crispatus CTV-05. 
 
6.1.2 
LACTIN-V 
6.1.2.1 
Background 
The Medicines Company originally licensed world-wide rights to a proprietary organism, 
Lactobacillus crispatus strain CTV-05, which had undergone clinical development as an 
adjunctive treatment for vaginal infections (Lactin-Vaginal).  Acquired in 1999 from a 
small biotech company, GyneLogix, Inc., in Louisville, Colorado, the product had been 
developed in conjunction with the NIH through completion of a Phase 2 study.  The 

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Medicines Company elected a strategic direction focusing on acute care products sold to 
hospitals and this led to a decision to out-license rights to continued development of 
this product to Osel, Inc. 
 
6.1.2.2 
The Product  
LACTIN-V contains Lactobacillus crispatus CTV-05 bacteria preserved by lyophilization in a 
simple freeze drying medium.  CTV-05 is a strain of Lactobacillus crispatus, a gram-
positive rod isolated from the vagina of a healthy woman. Lactobacillus crispatus is 
found naturally in the vaginas of healthy women and is commonly found as a 
component of the natural human intestinal microbiota.  It is a facultative anaerobe, 
homofermentor of lactic acid, fastidious in its growth, and capable of H2O2 production.  
Unlike most commercially available strains of Lactobacillus, CTV-05 adheres well to 
epithelial cells and is thus able to colonize the vaginal epithelium. The powder is loaded 
into an applicator for vaginal administration. The filled applicator is packaged under 
nitrogen with desiccant in a Mylar foil pouch. The manufacturing and formulation of this 
organism are carried out in a proprietary process.  
 
6.1.2.3 
Manufacturing and Packaging Information 
LACTIN-V contains Lactobacillus crispatus CTV-05 bacteria preserved by spray drying 
with a simple drying medium.  Lactobacillus crispatus is a naturally occurring organism 
isolated from the vagina of a healthy woman in 1993.  The final product appears as an 
off-white to light yellow powder, which is delivered as a vaginal applicator.  The 
applicators pre-filled and individually packaged.   
6.2 
Study Methods 
 
6.2.1 
Subject Selection 
6.2.1.1 
Recruitment 
The volunteers for this study will be recruited from Hall Health Primary Care Center at 
the University of Washington (Seattle, WA), as well as thru posted flyers and UW Daily 
Ads.  The study will follow Health Insurance Portability and Accountability Act (HIPAA) 
guidelines where applicable. 
 
6.2.1.2 
Eligibility 
6.2.1.2.1  Inclusion Criteria 
 
1. 
Pre-menopausal women aged 18–45 years of age at date of the 
Screening Visit. 

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2. 
Meets criteria for current symptomatic acute uncomplicated cystitis, 
defined as one or more UTI symptoms (dysuria, urgency, frequency, 
suprapubic pain), and pyuria (>10 wbc) on hemocytometer count, 
confirmed with a positive urine culture with greater than 102/ml of an 
uropathogen. 
3. 
Completion of all screening procedures. Screening will take place at the 
visit at which acute uncomplicated cystitis (UTI) diagnosis is made. 
4. 
History of one Symptomatic UTI episode treated within the past 12 
months. 
5. 
Agree to return for the Randomization Visit (Visit 1) within 3–10 days of 
completing antibiotic treatment for UTI. 
6. 
Regular menstrual cycles (21–35 days) or amenorrheic due to birth 
control method.  Women using IUD(C) must be 2 months post insertion 
of IUD. 
7. 
Subject is willing to insert vaginal applicators. 
8. 
Capable of providing informed consent. 
9. 
Able to read and understand English. 
10. Agree to abstain from self-medication with antibiotics for UTI 
symptoms.  
11. Agree to abstain from antibiotic prophylaxis for recurrent UTI. 
12. Agree to abstain from the use of any other intra-vaginal product (i.e., 
contraceptive creams, gels, foams, sponges, lubricants, douches, etc.). 
13. Agree to abstain from sexual intercourse for 24 hours after each 
applicator is inserted. 
14. Agree to not use tampons for 24 hours after each applicator is inserted. 
15. Agree to use an adequate method of birth control throughout study to 
avoid pregnancy. Acceptable methods include bilateral tubal-ligation, 
male partner with a vasectomy, steroidal contraceptive (oral, patch, 
injectable, implantable), IUD, condoms (to be provided), or abstinence.  
If condoms are used, they should be non-spermicidal condoms provided 
by the site.   
 
6.2.1.2.2  Exclusion Criteria 
 
1. 
Complicated cystitis or pyelonephritis (uncomplicated or complicated) 
2. 
Vaginal or cervical infection, currently or within the past 30 days, with bacterial 
vaginosis (treated, symptomatic infection), yeast, Trichomonas vaginalis, Neisseria 
gonorrhoeae, Chlamydia trachomatis or genital Herpes simplex.  

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3. 
Symptomatic BV and/or yeast at Visit 1 (women who have Asymptomatic BV at 
Visit 1 may participate in the study).  
4. 
High risk for sexually transmitted diseases and/or HIV, including: diagnosis of N. 
gonorrhoeae, C. trachomatis or T. vaginalis on two or more occasions during the 
previous six months; 
5. 
History of chronic vaginal, urinary or pelvic symptoms not attributable to UTI. 
6. 
Pregnancy or within two months of last pregnancy (all subjects must have a 
negative urine pregnancy test prior to randomization). 
7. 
Lactation. 
8. 
Antibiotic therapy (vaginal or systemic) less than three days prior to Randomization 
Visit (Visit 1). 
9. 
Antifungal therapy (vaginal or systemic) less than thirty days prior to the 
Randomization Visit. 
10. Antibiotics planned within four months (including prophylactic antibiotics). 
11. Investigational drug use within 30 days or current participation in any urogential 
studies. 
12. Menopause. 
13. Any significant disease or acute illness that in the Investigator’s assessment could 
complicate the evaluation. 
14. Known HIV infection. 
15. Immunosuppressive drug within 60 days. 
16. Known allergy to any component of LACTIN-V or the placebo capsule. 
17. Unavailable for follow-up visits. 
18. Have 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. 
 
Subjects who develop the following exclusion criteria while on study will discontinue 
study treatment, but continue to be followed for safety and efficacy endpoints 
whenever possible.  
• Pregnancy 
• Lactation 
• HIV infection 
• Treatment with immunosuppressive drug 
• Allergy to LACTIN-V or placebo capsule 
 

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Subjects who develop any other exclusion criteria while on study will be managed at the 
discretion of the Investigator, in consultation with the Medical Monitor. 
 
6.2.1.3  
Screening Failures and Subject Replacement 
Volunteers with the following diagnoses at Visit 1 will be considered screening failures 
and will be treated or referred for appropriate follow-up.  All screening failures will be 
replaced.  
 
1. Complicated cystitis or uncomplicated or complicated pyelonephritis. 
2. Abnormal findings on pelvic examination that would interfere with the evaluation of 
safety.  
a. Unable to visualize cervix. 
b. Clinically significant inflammation, erosions and/or petechiae of external 
genitalia, vagina or cervix on visual examination. 
c. Clinically significant tenderness on bimanual examination. 
3. Evidence of a sexually transmitted disease. 
4. Symptomatic BV or yeast. 
 
6.2.1.4 
Withdrawal of Randomized Subjects  
Study subjects who have been randomized may be withdrawn from receiving further 
investigational product for the following reasons: 
1. 
Allergy to the study product. 
2. 
Adverse event. 
3. 
Unable or unwilling to use LACTIN-V applicators for the duration of the study. 
4. 
Failure to follow protocol requirements that would significantly affect study 
outcomes. 
5. 
Pregnancy. 
6. 
Medical reasons unrelated to study products.   This determination will be at the 
discretion of the Investigator, but might include major new diagnoses such as a 
malignancy requiring chemotherapy. 
7. 
Personal reasons (voluntary request or withdrawal of consent). 
8. 
Physician decides that it is not in the best interest of the subject to continue 
participation. 
9. 
Physician or sponsor decides, for whatever reason, to discontinue the study. 
 

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For randomized subjects who are withdrawn from receiving further product, the site will 
make every effort to continue to follow all subjects for efficacy through duration of 
study. 
 
6.2.1.5 
Discontinuation and Subject Replacement 
The study subject may choose to leave the study at any time.  Reasons for leaving the 
study will be recorded.  Study subjects who enroll in the study but who do not return 
after three attempts to contact them will be considered study “lost to follow-up”. 
 
Once a subject is randomized, she will not be replaced.  Withdrawals and drop-outs will 
not be replaced. 
 
6.2.2 
Blinding and Unblinding of Treatment Assignment 
6.2.2.1 
Blinding 
The most important factor for the success of a blinded study is to maintain the blind 
throughout the entire course of the trial.  In this study, the treatment assignment to 
LACTIN-V and the placebo applicator will be maintained by Pacita Roberts, M.S., the 
study statistician.  Treatment assignment will be blinded to all other study staff and 
subjects.  
  
The study product will be prepackaged in accordance with a previously generated 
randomization schedule.  It will be supplied to the study site labeled only with the 
Protocol Number and Subject Number.  As study product is shipped to the sites, a list of 
Subject Numbers that corresponds to the study product will be enclosed. 
 
A block size of four has been chosen to minimize the potential imbalance between 
LACTIN-V and placebo.  Within each block, subjects will be randomized in a 1:1 ratio to 
receive either LACTIN-V or placebo.  Subjects will be randomized on site in sequential 
order based on the list of Subject Numbers provided to the site.  Lists will not have any 
treatment assignment associated with the Subject Number. 
 
Applicators will be individually packaged.  No one involved in the conduct of the trial will 
be aware of the specific treatment allocated to any particular subject.  Only authorized 
persons, including the study statistician, will have access to treatment assignments in 
case of necessary unblinding (see below).  The LACTIN-V applicator cannot be 
distinguished from the placebo applicator (appearance or smell) either before or during 
administration.   
 

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6.2.2.2 
Unblinding 
Breaking the blind on an individual basis should be considered only when knowledge of 
the treatment assignment is considered essential by the subject’s physician for her care.  
In the event of an emergency situation for which knowledge of the treatment 
assignment is necessary for clinical management, the site should notify the Medical 
Monitor or Clinical Program Manager.  Any unintentional unblinding should be reported 
immediately to Ann Stapleton, M.D. documented during the trial, and reported and 
explained at the end of the trial in a study report, irrespective of the reason for its 
occurrence.  
 
6.2.2.3 
Unblinding Procedure 
Tamper-proof envelopes containing treatment group assignment for each Subject 
Number will be available to Pacita Roberts, M.S. The tamper-proof envelopes will be 
stored in a secured location for emergency unblinding purposes only.  If the Investigator 
determines that a subject has experienced a significant adverse event that may be 
related to the study product and requires unblinding in order to make patient care 
decisions, he or she should notify the Medical Monitor and Clinical Program Manager 
immediately.  A Request for Emergency Unblinding Form, with the Subject Number, 
date, time, person making the request, description of the serious adverse event, onset 
date, and the reasons for unblinding, will be faxed to the Medical Monitor and Clinical 
Program Manager for review.  If unblinding is approved, an authorized person at the 
University of Washington will open the tamper-proof envelope for the individual subject 
and promptly report the treatment assignment to the Investigator.  In the event that the 
Medical Monitor or Clinical Program Manager cannot be reached quickly, the 
Investigator will be provided with a list of representatives who may be contacted to 
request emergency unblinding.  An emergency unblinding log will be maintained by 
University of Washington. 
 
6.3 
General Procedures 
6.3.1 
Informed Consent 
Women who attend a study clinic (or referring clinic) for urinary symptoms and are 
diagnosed with acute, uncomplicated UTI (including acute uncomplicated cystitis) will be 
advised that a study is underway.  They will be asked if they would like to hear more 
about the research.  If they are interested, written informed consent will be obtained 
from each study subject prior to commencing any procedure or assessment associated 
with the Screening Visit (Visit 0).  Study subjects will receive a copy of the signed and 
dated Informed Consent Form (ICF).  If the ICF is altered during the study, subjects will 
be re-consented with the IRB-approved revised ICF, and a copy of the new signed 
consent form will be provided to the subject.  

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6.3.2 
Confidentiality of Records 
Informed consent forms, contact information, and other data collection instruments 
containing personal identifiers will be securely stored separately in locked offices 
located at the project site.  Only limited study site staff will have access to these files.  
Only a study identification number will identify the subject in research records. All data 
will be encoded and entered into a computer using the Subject ID. 
 
6.3.3 
Visit 0 
Visit 0 is the Screening Visit.  This visit is conducted at the time of the UTI diagnosis.   
 
• 
Visit 0 will occur on the day that the UTI is diagnosed. 
 
Each woman who agrees to be screened will be asked to sign the informed consent form 
written in English.  The screening process will be explained to interested women and 
written informed consent will be obtained from each woman who agrees to participate.  
The subject will be asked to provide either a contact phone number or email address, 
which will be recorded on a subject contact information form.  This will be used to 
remind subjects of follow-up visits. 
 
Women who give informed consent to enrollment will undergo the following 
procedures and assessments at Visit 0: 
 
1. 
Detailed structured interview to obtain medical and sexual history.  This will 
include assessment of STD and HIV risk. 
2. 
Review eligibility criteria. 
3. 
Vital signs and weight. 
4. 
Clean catch urine dipstick performed in clinic, with urinalysis, culture and 
susceptibility testing sent to research laboratory. 
5. 
The subject will then undergo a physical examination and focused genital 
examination by a study physician or nurse.. 
6. 
Pelvic examination, to be conducted in the following order: 
a. Examination of the external genitalia 
b. Vaginal swab for pH, wet mount (clue cells and trichomonas), KOH and amine 
test (whiff test) performed in clinic. 
c. Swab of vaginal fluid to be stored for assessment of vaginal microbiota by DNA 
amplification. 
 

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Women diagnosed with any symptomatic vaginitis at Visit 0 will be treated and excluded 
from the study.   
 
6.3.4 
Visit 1  
Visit 1 is the Randomization Visit.  This visit will be scheduled if urine culture confirms the 
presence of a uropathogen in quantity greater than or equal to 102/ml.    
 
• 
Visit 1 must occur within 3–10 days of completing the antibiotic, and after the 
subjects’ anticipated menses.   
 
It is possible that the entry UTI episode will not be fully resolved at the time of 
randomization (Visit 1), as mild symptoms may still be present, and the dipstick and 
urinalysis may still be slightly positive or equivocal several days after completing 
antibiotics.   
 
The following procedures and assessments will be performed at Visit 1: 
 
1. 
Eligibility confirmed. 
2. 
All baseline symptoms to be recorded on the CRF.  
3. 
Urine pregnancy test performed in clinic. 
4. 
Clean catch urinalysis and culture. 
5. 
Vital signs.  
6. 
Pelvic examination, to be conducted in the following order: 
a. Examination of the external genitalia 
b. Speculum insertion and examination of vagina, fornices and cervix 
with naked eye.  Only water must be used to lubricate the speculum 
at all study visits.  Other lubricants could kill L. crispatus. 
c. Vaginal swab for pH, wet mount (clue cells), KOH and amine test 
(whiff test) performed in clinic. 
d. Vaginal swab for gram stain Nugent score. 
e. Vaginal swabs for culture (total lactobacilli and E. coli) and rep-PCR. 
f. Swab of vaginal fluid to be stored for assessment of vaginal 
microbiota by DNA amplification. 
g. Bimanual examination 
7. 
Subject randomized. 
8. 
First investigational applicator inserted under supervision. 
9. 
Instructions provided to subject regarding: 

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a. Study Diary 
b. Dates for initial 5 day applicator use and weekly applicator use 
will be marked on the Study Calendar, and staff will review 
with the subject how to record. If subject experiences 
unanticipated menses she may defer scheduled applicator use 
and will then record the day of actual use. 
 
6.3.5 
Visits 2 thru 5  
The following procedures and assessments will be performed at follow-up Visits 2 thru 5 
(unless otherwise specified): 
 
1. 
All reported AEs to be recorded on the AE CRF. 
2. 
Clean catch urine dipstick performed in clinic. 
3. 
Urinalysis and urine culture. 
4. 
Urine pregnancy test performed in clinic only if clinically indicated. 
5. 
Focused physical examination, if indicated for assessment of symptoms and 
adverse events. 
6. 
Pelvic examination to be conducted in the following order:  
a. Examination of the external genitalia. 
b. Vaginal swab for pH, wet mount (clue cells), KOH and amine test (whiff test) 
performed in clinic.  
c. Vaginal swabs for culture (total lactobacilli and E. coli) and rep-PCR sent to 
laboratory  
d. Vaginal swab for gram stain Nugent score sent to laboratory (Visit 5 only). 
e. Swab of vaginal fluid to be stored for assessment of vaginal microbiota by DNA 
amplification. 
7. All diagnoses of UTI are to be recorded on the UTI CRF.   
 
Subjects diagnosed with Symptomatic UTI during study participation are to be treated as 
clinically indicated and should continue to use study applicators as scheduled.   
 
6.3.6 
Additional Unscheduled Visits 
Subjects will be instructed to return to the site if they experience symptoms of UTI 
during the four-month study period, or to report an adverse event that requires further 
evaluation. 
 

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The following list of procedures and assessments for the Unscheduled Visits is a guide 
only.  The components of the history and physical examination conducted at this visit 
will be determined by the Investigator or his/her designee.  All history and physical data 
from this visit should be recorded on the Symptomatic Visit CRF: 
 
1. 
Focused physical examination, if indicated for assessment of symptoms. 
2. 
Pelvic examination, if indicated for assessment of symptoms.  A pelvic examination 
should be performed for all vaginitis symptoms and should be conducted as 
follows:  
a. Examination of the external genitalia. 
b. Speculum insertion and examination of vagina, fornices and cervix with naked 
eye. Only water must be used to lubricate the speculum at all study visits.  
Other lubricants could kill L. crispatus. 
c. Vaginal swab for pH, wet mount, KOH, clue cells and amine test (whiff test) 
performed in clinic. 
d. Swab of vaginal fluid to be stored for assessment of vaginal microbiota by DNA 
amplification. 
3. 
Clean catch urine collection for dipstick, urinalysis, and/or urine culture with 
susceptibility testing if indicated.  Urine testing should be conducted for all urinary 
symptoms while on study. 
4. 
All diagnoses of UTI are to be recorded on the UTI CRF.  Subjects diagnosed with 
UTI during study participation are to be treated as clinically indicated and should 
continue to receive study treatment.   
If the subject has a new symptom (or increase in the severity of an existing symptom), 
the AE CRF and if necessary, the SAE CRF, should be completed.  
 
6.3.7 
UTI Episodes While On Study 
Subjects will be instructed to return to the study site if they have persistent or new 
urinary symptoms.  If a UTI is diagnosed by a non-study physician, medical records for 
that visit will be obtained in order to document the recurrence of UTI. 
 
All antibiotics used to treat UTI should be recorded on the Concomitant Medications 
Log. 
6.4 
Clinical Procedures/Evaluations 
6.4.1 
Pelvic Examinations 
Each subject will be examined in the dorsal lithotomy position in designated 
examination rooms.  Only water must be used to lubricate the speculum at all study 
visits.  Other lubricants could kill L. crispatus. 

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6.4.2 
Investigational Product Instructions 
At Visit 1 (Randomization Visit), each study subject will be counseled on how to use the 
applicators.  Written instructions for administration, storage and handling will be 
provided to each study subject (Appendix B), along with a Study Diary to record 
applicator use times and symptoms throughout the study. Each subject will be 
instructed to use the applicator on scheduled days, and weekly insertion dates will be 
marked on the Study Diary, which the subject will take home.   
 
Instructions will be given regarding what to do in the event that the subject forgets to 
use an applicator on the prescribed day (see Section 6.6). 
 
Subjects will be instructed to defer insertion of applicators on days of heavy menstrual 
flow.   
 
Information will be reviewed with the study subject at each of the follow-up visits, and 
study personnel will address any questions or concerns that may arise.  
 
Subjects will be asked to return both used and unused applicators.   
 
6.5 
Early Discontinuations 
If a study subject should discontinue the study prior to Visit 6, all end of study 
procedures and CRFs should be completed. 
 
6.6 
Missed Applicators 
During the initial five-day treatment period, if it is already within eight hours of her next 
dose, she should skip the missed applicator.  The subject should record the missed dose 
on the Study Diary. After Day 5, if a subject misses an applicator, she should be 
instructed to use the missed applicator as soon as possible (but no more than four days 
from the scheduled date) and the date should be recorded on the Study Diary. 
6.7 
Lost Applicators 
Extra applicators will be provided to each subject together with the required 13 
applicators.  If a subject loses or damages a study applicator, she may take one of the 
extras provided, as long as the total number of applicators used does not exceed 13. 
Lost or damaged applicators should be documented on the Study Diary. 

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6.8 
Antibiotic Use While On Study 
All subjects who receive antibiotics during the four-month study period for UTI or any 
other infection may remain on study and continue study treatment.  All antibiotic use 
should be reported on the Concomitant Medication Log CRF.   
 
6.9 
Laboratory Procedures 
6.9.1 
Specimen Collection and Processing 
• 
Wet Mount Slides (All Visits): Wet mount slides will be evaluated for signs of 
BV (clue cells), trichomonas and/or candida (yeast). If vaginal symptoms 
develop during the study, additional wet mounts will be done as 
indicated. These tests will be done in the clinical laboratory of the UTI 
Research Unit at the Hall Health Primary Care Center. 
• 
Urine Dipstick Testing (All Visits): A clean catch urine sample will be tested 
on site for the presence of red blood cells, white blood cells, nitrite, 
leukocyte esterase and protein.   
• 
Urine Pregnancy Test (Visits 1 and 6): A urine sample will be tested on site to 
confirm the absence of pregnancy.  
6.9.2 
Laboratory Testing 
All testing will be performed in the laboratory of Ann E. Stapleton, M.D. at the University 
of Washington. 
• 
Urine Hemocytometer (All Visits): Will be performed during the study visit at 
Hall Health. Urine samples will be assessed for red blood cells and white 
blood cells. 
• 
Urine Dipstick (All Visits) Will be performed during the study visit at Hall 
Health. Urine samples will be assessed for LE, nitrite and blood. 
• 
Urine Culture (All Visits):  Cultures of midstream, voided clean catch urine 
samples will be performed in the lab of Ann E. Stapleton, M.D. at the 
University of Washington. 
• 
Culture of vaginal specimens for Gram stain (All Visits): A sterile swab will 
be used to collect fluid from the vaginal walls.  Gram stain and cultures will 
be done in the lab of Ann E. Stapleton, M.D. at the University of Washington. 
• 
Lactobacillus culture and rep-PCR for Lactobacillus CTV-05 (All Visits): A 
sterile swab will be used to collect fluid from the vaginal walls.  Specimens 
will be analyzed by culture and rep-PCR in the lab of Ann E. Stapleton, M.D.  
at the University of Washington. 

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• 
E. coli culture (All Visits): A sterile swab will be used to collect fluid from the 
vaginal wall. Specimens will be analyzed by culture in the lab of Ann E. 
Stapleton, M.D. at the University of Washington. 
• 
Qualitative and/or quantitative DNA amplification of vaginal microbiota:  A 
sterile swab will be used to collect fluid from the vaginal walls at each visit 
and stored.  DNA amplification will be performed in the lab of Ann E. 
Stapleton, M.D. at the University of Washington. 
 
6.9.3 
Compliance Monitoring 
The study subject will be questioned at Visits 2-6 regarding her use of the applicators 
and any symptoms she experienced during or following applicator use.  
7 
MANAGEMENT OF ADVERSE AND OTHER EVENTS 
7.1 
 
Adverse Events  
An adverse event (AE) is any untoward and/or unintended sign, including an abnormal 
laboratory finding, symptom, or disease temporally associated with the use of an 
investigational product, whether or not considered related to the investigational 
product.  Pre-existing events or conditions that increase in frequency or severity during 
or as a consequence of use of a drug in human clinical trials will also be considered 
adverse events.  Any medical condition or clinically significant laboratory abnormality 
with an onset date before the first date of study product administration is considered to 
be a pre-existing condition and should be documented as such. 
 
In this protocol, pregnancy will be considered to be an AE, and will be followed for 
outcome. 
 
7.1.1  
Adverse Event Recording  
Adverse events may include illnesses, discomfort, pain, or any medical problem such as 
cold symptoms or other complaints. They may be clinically significant laboratory 
abnormalities, or pre-existing conditions which change in severity or nature during the 
course of the protocol. All AEs, whether serious or non-serious and whether or not 
related to the study product, must be recorded on the Adverse Event (AE) page of the 
case report form. Study subjects will be instructed to call or return to the study clinic if 
they have any unexpected symptoms.  
 
7.1.2  
Adverse Event Grading 
Each AE should be graded for severity using the following scale: 
 

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• Mild: the subject was aware of the AE, but was still able to do all 
activities; no or minimal medical intervention/therapy required. 
• Moderate: the subject had to discontinue some activities due to the AE; 
no or minimal medical intervention/therapy required. 
• Severe: the subject was incapacitated by the AE and unable to perform 
normal activities; significant medical intervention/therapy required, 
hospitalization possible. 
• Potentially life-threatening: An adverse event or suspected adverse 
reaction is considered "life-threatening" if, in the view of either the 
investigator or sponsor, its occurrence places the patient or subject at 
immediate risk of death. It does not include an adverse event or 
suspected adverse reaction that, had it occurred in a more severe form, 
might have caused death.  
 
7.1.3  
Assessment of Causality 
Each AE should be assessed for its causal relationship to the study product. The 
Investigator is responsible for making an assessment of whether or not it is reasonable 
to suspect a causal relationship between an AE or SAE and the administration of the 
investigational product. The causality assessment will be reviewed by Ann Stapleton, 
MD and the Medical Monitor. The assessment of causality will only be reclassified by the 
Investigator.  “Associated with the use of the drug” means: “There is a reasonable 
possibility that the experience may have been caused by the drug.”  
 
In assessing causality the following should be considered: 
 
• Alternative etiology - Is the AE due to the underlying disease being treated or is the 
AE a new diagnosis? 
• Known relationship – Has the AE been observed before with this investigational 
product or class? 
• Temporal relationship – What was the time of onset and resolution in relationship to 
the receipt of the investigational product? 
• Concomitant medication – Is the AE a known side effect of another medication? 
• Re-challenge – Does re-challenge result in recurrence of the AE? 
 
For each AE, an assessment of the relatedness to the test agent should be made using 
the following scale: 
 
• Not Related: Onset of the AE has no reasonable temporal relationship to 
administration of the investigational product, a causal relationship to administration 

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of the investigational product is biologically implausible or the event is attributed to 
an alternative etiology. 
• Unlikely Related: Onset of the AE has a reasonable temporal relationship to study 
product administration and although a causal relationship is unlikely, it is biologically 
plausible. 
• Possibly Related: Onset of the AE has a strong temporal relationship to 
administration of the investigational product, cannot be explained by the subject’s 
clinical state or other factors, and a causal relationship is biologically plausible. 
• Probably or Definitely Related: Onset of the AE shows a distinct temporal 
relationship to administration of the investigational product that cannot be 
explained by the subject’s clinical state or other factors, or the AE occurs on 
rechallenge, or the AE is a known reaction to the product or chemical group, or can 
be predicted by the product’s pharmacology. 
 
7.2  
Serious Adverse Events 
A serious adverse event (SAE) is any adverse event occurring at any dose that 
meets the following criteria: 
• results in death 
• is life-threatening 
• requires hospitalization or prolongation of existing hospitalization  
• results in persistent or significant disability/incapacity 
• is a congenital anomaly/birth defect 
• the event was another, important medical event that may not have met 
the above criteria but based upon appropriate medical judgment, it 
jeopardized the subject or required medical or surgical intervention to 
prevent one of the outcomes listed above  
 
Any AE that is serious (whether expected or unexpected) must be reported by facsimile 
within 24 hours of the Investigator or site staff becoming aware of the event to Ann E. 
Stapleton, M.D., and the University of Washington Institutional Review Board.  Sites will 
use Adverse Event Reporting Forms when submitting SAE reports.   
 
It is the responsibility of the Investigator to report all SAEs to the sponsor, to provide the 
most complete report possible, and to assess each SAE for its relationship to the study 
product. Each SAE occurring in this study must be followed to resolution.  
 
The study will be suspended or stopped if two or more product-related SAEs are 
reported. 

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7.3  
Unexpected Adverse Events 
An unexpected adverse event is any AE having a specificity or severity not consistent 
with the current Investigator Brochure.  
 
7.4  
Serious Adverse Event Reporting 
All serious adverse events (SAEs) must be reported to Ann E. Stapleton, M.D. and the 
Medical Monitor as follows:  
 
• Any AE that is serious (whether expected or unexpected) must be reported by facsimile 
or email to Ann E. Stapleton, M.D. and the University of Washington Institutional 
Review Board using the University of Washington Event Reporting Forms within 24 
hours of the Investigator or site staff becoming aware of the event.   
• All SAE reports should include the Investigator’s assessment of the relationship of the 
event to the study product.  
Any subject with an SAE, whether or not considered related to the study product or 
procedures, will be discontinued from further study treatment.  
 
7.5  
Regulatory Reporting of Serious Adverse Events 
In the event of a fatal or life-threatening SAE, Ann E. Stapleton, MD will notify the FDA 
by telephone or facsimile within seven calendar days of receipt of the report. Ann 
Stapleton, M.D. will follow all 7-day alert reports with a written IND safety report within 
15 calendar days of receipt of the case.  
 
Serious adverse event cases that concern non-fatal, non-life-threatening events which 
are unexpected and at least possibly related to the study product will be submitted in 
writing to the FDA as 15-day IND safety reports within 15 calendar days of receipt.  
 
Ann Stapleton, MD will require Investigators to obtain follow-up information on all SAEs.  
 
7.6  
Unblinding of Study Treatment Assignment 
If during the course of the blinded portion of this study a medical emergency requires 
knowledge of a subject’s treatment assignment, the study blind may be broken by 
authorized persons for that specific subject.   
 

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7.7  
Pregnancy 
If a woman becomes pregnant while on study, this should be reported immediately to 
the Investigator and the Medical Monitor.  All pregnancies will be recorded as an AE and 
will be followed for outcome.  
 
8   
GENERAL ADMINISTRATIVE PROCEDURES 
8.1 
Protocol Modifications  
Protocol modifications will be avoided to the extent possible.  Potential modifications 
include (but are not limited to) refinement of counseling strategies and recruitment 
techniques, revision of questionnaires and other subject-related documents, and 
refinement of intervention. Any protocol modification must be approved by Ann 
Stapleton, M.D. prior to implementation. Protocol amendments will be submitted to the 
IRB as indicated, depending upon the nature of the modification. 
 
8.2  
Clinical Monitoring 
There will be no independent data monitoring committee for this Phase 3 study.  
 
The Medical Monitor and Principal Investigator will regularly review the safety data 
throughout the course of the study. 
 
8.3 
Individual Stopping Rules 
Any subject with an SAE, whether or not considered related to the study product or 
procedures, will be discontinued from further study treatment. 
 
8.4 
Study Suspension or Termination 
As stated above, any SAE must be reported by the Investigator or designee to Ann 
Stapleton, M.D. and the Medical Monitor.  The study will be suspended if two or more 
SAEs considered “Possibly” or “Probably” related to the product are reported in any 
study of LACTIN-V.  The study will only be resumed if the Medical Monitor and the FDA 
agree to do so.  Study suspension or termination will be reported to the University of 
Washington IRB. 
 
8.5 
Roles and Responsibilities of the Study Site 
The study site has the following responsibilities: 
 
• Complete the site University of Washington IRB application. 

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• Complete the following prior to study start: signature(s) on any applicable clinical trial 
agreements, FDA forms, financial disclosures, debarment certifications and protocol 
signature page; CVs and medical licenses (if applicable) of all Investigators; and, if 
applicable, recruitment materials and laboratory documentation.    
• Conduct the study under procedures defined by GCP (Good Clinical Practices). 
• Report all new or updated SAE information promptly to Ann Stapleton, M.D. and the 
University of Washington’s IRB within 24 hours of first knowledge. 
• Report any instances of unintentional unblinding immediately to Ann Stapleton, M.D. 
• Submit all significant protocol deviations promptly to University of Washington’s IRB  
• Resolve all queries regarding the data that arise in the course of the study.. 
• Provide clinical laboratory services where required by the protocol. 
• Obtain annual approval from University of Washington’s IRB. 
• Complete monthly update and submit to Ann Stapleton, M.D. in report form on the first 
business day of each month during the study. 
• Submit all Expedited Safety Reports and Investigator Letters to University of 
Washington’s IRB within three business days of receipt.  
 
8.6 
Protocol Deviations 
All significant protocol deviations that the Investigator or site staff believes are of major 
importance (for example, incorrect randomizations, subject enrolled but not eligible) 
should be reported to Ann Stapleton, M.D. as soon as possible. Significant protocol 
deviations may include the following: 
• 
Deviations from the Inclusion/Exclusion criteria that may affect 
subject safety. 
• 
Deviations (omission or delay) of safety monitoring procedures. 
• 
Deviations in the administration of study product. 
• 
Deviations in obtaining informed consent. 
 
Significant protocol deviations will be reported to the University of Washington IRB, and 
will also be recorded on the CRF using the Significant Protocol Deviation page.  These 
forms will be completed and faxed to the IRB.   
 
 
All protocol deviations occurring at each site that are not recorded on these forms will 
be listed in the Protocol Deviation Log, which will be routinely reviewed by the principal 
investigator. 
 

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9 
DATA MANAGEMENT 
9.1 
Data Collection and Entry 
Case Report Forms (CRFs) will be completed at the study site with only the subject 
identification (Subject ID), which consists of a 2-digit site number and a 4-digit 
randomization number (the Subject Number).  CRF’s will be forwarded to the University 
of Washington for entry onto datasets using Teleform scanning software (Cardiff 
Software, Inc.).  These datasets will be transferred electronically to the study 
statistician, who will manage and analyze the data.  At several points during the project, 
the data will be examined for out-of-range values, missing data and logical 
inconsistencies, and adjustments will be made as needed.  Final analysis files will be 
created at the conclusion of data collection and clean-up.  Once the last subject has 
completed Visit 6 and data are cleaned, all analyses will be performed on the data sets 
through Visit 6.  Data will be managed and analyzed using a combination of local and 
centralized computing resources at the University of Washington.  SAS will be used for 
data management. 
10 
STATISTICAL CONSIDERATIONS 
10.1 
Primary Endpoint 
The primary endpoint of this Phase 2 study is to evaluate the efficacy of Lactobacillus 
crispatus strain CTV-05 (LACTIN-V) in pre-menopausal women who have a history of 
recurrent uncomplicated UTI when the product is administered vaginally at a dose of 2 x 
109 CFU/capsule once per day for five consecutive days followed by once per week for 
10 weeks.  The main analysis of interest will be the comparison of UTI during the follow-
up period, looking at: 
 
1. UTI incidence over the 16-week study period in the LACTIN-V treatment 
group (Group A) as compared to the placebo group (Group B) of: 
a. Symptomatic or Probable UTI 
b. Symptomatic UTI 
2. Time to recurrence, as measured from date of the Randomization Visit 
(Day 1) to the date of first UTI diagnosis post-randomization, in the 
LACTIN-V group (Group A) compared to the placebo group (Group B) of: 
a. Symptomatic or Probable UTI 
b. Symptomatic UTI 
3. Comparison of the number (%) of subjects over the 16-week study period 
with at least one: 
a. Symptomatic or Probable UTI 
b. Symptomatic UTI 

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10.2 
Secondary Endpoints 
The secondary endpoints of this study are parameters of vaginal environment and 
colonization and adverse events due to the study product. 
 
1. Vaginal colonization with total lactobacilli (as assessed by vaginal culture) and 
Lactobacillus crispatus strain CTV-05 (as assessed by rep-PCR) at Visits 1 through 6 in 
the LACTIN-V group (Group A) as compared to the placebo group (Group B). 
2. Vaginal colonization with E. coli, in the LACTIN-V group (Group A) as compared to 
the placebo group (Group B), as assessed by the presence of E. coli on vaginal 
culture at Visits 1 through 6. 
3. Shifts in the vaginal microbiota of individual subjects, as assessed by Nugent score of 
vaginal gram stains at Visits 1 through 6, in the LACTIN-V group (Group A) as 
compared to the placebo group (Group B). 
4. Shifts in the composition of vaginal microbiota, as assessed by qualitative and/or 
quantitative DNA amplification of stored vaginal specimens from all visits. 
5. Presence and/or quantitation of H2O2, lactic acid, and cytokine profiles at Visits 1 
through 6, in the LACTIN-V group (Group A) as compared to the placebo group 
(Group B). 
6. Safety and tolerability will be evaluated by the number (%) of subjects with any 
treatment emergent adverse event, reported symptoms and/or abnormal pelvic 
examination results over the four-month study period. 
 
10.3 
Measurement 
There are six scheduled study visits during which clinical assessment and measurements 
will be made in this study: 
 
 
Activity 
Schedule 
Visit 0 
Screening 
Visit 1 
Randomization (Day 3-10 post antibiotics) 
Visit 2 
Week 3 
Visit 3 
Week 6 
Visit 4 
Week 10 
Visit 5 
Week 14 
Visit 6 
Week 18 
 
Safety will be assessed at each visit using self-reported adverse events, symptoms and 
pelvic examination findings.  Pelvic examinations at each visit will be used to evaluate 
subjects for signs of irritation involving the external genitalia, cervix or vagina. 
 

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The presence of a Symptomatic UTI episode will be assessed at each visit by the 
investigator using the case definitions in Section 3.3.  Subjects will also be queried at 
each study visit regarding any Probable UTI episodes, which may have occurred since 
the prior visit. The number of days from the date of the Randomization Visit to the date 
when a recurrence of UTI is first diagnosed will be used to calculate the time to UTI 
recurrence.  A new on-study UTI (Symptomatic or Probable UTI) can only be diagnosed 
after the urine culture at Visit 1, or at another interim study visit after confirming 
resolution of the prior UTI. 
 
Vaginal microbiota will be assessed using the Nugent Scoring System for Gram Stained 
Vaginal Smears at Visits 1 through 6. Vaginal cultures of total lactobacilli and E. coli will 
be evaluated at Visits 1 through 6.  Colonization with the exogenous Lactobacillus 
crispatus strain CTV-05 will be evaluated by the presence or absence of CTV-05 by rep-
PCR at Visits 1 through 6.  Vaginal fluid specimens from each visit will be stored for 
assessment of shifts in the composition of vaginal microbiota using qualitative and/or 
quantitative DNA amplification methods.  Presence and/or quantity of H2O2, lactic acid, 
and cytokines will be assessed. 
 
10.4 
Statistical Power and Sample Size Justification 
Based on previous studies in this population, we estimate that 40% of women with a 
history of rUTI and recent treatment for a UTI will have a recurrence within the 4 month 
follow-up period, based on data from a recently completed rUTI study at this site (17).   
We plan to enroll 250 women to allow for >80% power to detect a 50% reduction in UTI 
incidence, also factoring in some drop-out, non-compliance and loss-to-followup, plus a 
cushion in case of a recurrence rate of less than 40%. 
 
10.5 
Study Instruments 
Responses to safety questions, results of clinical examinations, and results of laboratory 
testing will be recorded on source documents for visits and laboratory evaluations. 
 
The study will continue enrolling subjects until all subjects are enrolled and have 
completed Visit 6, or until there is any finding that warrants change in study procedures, 
as explained previously (see Section 7.2 and 7.4). 
 
10.6 
Randomization 
Subjects will be randomized in a double-blind fashion. The randomization assignments 
will be produced using a computerized blocked randomization process, assigning equal 
numbers of subjects to either intervention or placebo. The randomization assignments, 
along with the sequentially assigned identifying number (ID#), will be given to the Hall 
Health pharmacy, where the probiotic/placebo will be packaged into identical envelopes 

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marked with the ID# prior to distribution to clinic personnel. Subjects who have 
successfully completed the Screening Visit and the Visit 2 pre-randomization 
assessments will be randomized sequentially as they become eligible for the study. 
 
10.7 
Cohorts for Analyses 
The intent-to-treat (ITT) cohort is defined as subjects who are randomized in the study. 
 
The modified intent-to-treat (MITT) cohort is defined as subjects who are randomized 
and have received at least one dose of study product. It is a subset of the ITT cohort. It 
will be used for analyses of primary and secondary endpoints, baseline characteristics, 
trial conduct, and significant protocol deviations. 
 
The evaluable (Eval) cohort is defined as the subset of the MITT cohort who had at least 
one follow-up visit assessment post-baseline (Visit 2 or later) and are not an antibiotic 
treatment failure at Visit 1 (defined as a requiring treatment for UTI symptoms at Visit 
1). Subjects with any significant protocol deviations may be included in this cohort. 
 
The according-to-protocol (ATP) cohort is the subset of Eval with subjects who meet all 
protocol specifications. Those subjects who developed exclusion criteria while on study 
will be excluded from this cohort. 
 
Both Eval and ATP cohorts will be used to analyze the primary endpoints. 
 
10.8 
Analysis Methods 
Summary statistics of frequencies, percentages, and 95% confidence intervals will be 
provided for categorical data.  Means, standard deviations (SD), medians, and ranges 
(minimum, maximum) will be provided for continuous data.  Chi-square test (Cochran-
Mantel-Haenszel [CMH] methods), Fisher’s exact test, or McNemar’s test will be used 
for categorical variable comparisons and a t-test or rank-sum test will be used for 
continuous variable comparisons.  Specifically, the following table lists the key variables 
to be analyzed by endpoint. 
 
 
 
 
 
 
 
 
 
 

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Table 1 
 
 
Analysis Variables and Methods  
 
Endpoint 
Variable 
Type 
Statistics 
Method 
Primary 
Percent of subjects with 
any 
Symptomatic/Probable 
UTI  
Categorical Frequency, 
Percent 
95% confidence 
intervals 
 
Incidence of 
Symptomatic/Probable 
UTI  
Categorical Frequency, 
Percent 
CMH  
 
Time to recurrence of 
first Symptomatic UTI  
Numeric 
Mean time 
to 
recurrence 
Survival 
analysis, log 
rank test 
Secondary Change in vaginal 
microbiota (Nugent 
score) 
Categorical Frequency, 
Percent 
Shift table 
(from Visit 1 to 
Visit 6), CMH 
Total Lactobacillus vaginal 
colonization 
Categorical Frequency, 
Percent 
95% confidence 
interval at Visits 
1-6 
Colonization with CTV-05 
Categorical Frequency, 
Percent 
95% confidence 
interval at Visits 
1-6 

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10.9 
Analysis of Primary Endpoint 
10.9.1 
Recurrence Rate of UTI 
The number (%) of subjects with any Symptomatic/Probable UTI (defined in Section 3.3) 
episode over the four-month study period will be assessed, as well as the number (%) of 
subjects with Symptomatic UTI.  The number (%) in each treatment group will be 
presented.  95% confidence intervals will be calculated to evaluate any difference 
between the treatment groups.     
 
10.9.2 
Incidence of Symptomatic UTI episodes 
The number of Symptomatic/Probable UTI (defined in Section 3.3) episodes per subject 
in each treatment group will be summarized by treatment group, as well as the number 
Symptomatic UTI episodes.  Number and percent of subjects with 0, 1, 2, …, n episodes 
will be displayed by treatment group.  P-value will be calculated by CMH methods to 
evaluate any difference between the treatment groups.  
 
10.9.3 
Time to Recurrence of the first Symptomatic/Probable UTI episode 
The time (number of days) to the first recurrence of Symptomatic/Probable UTI, as well 
as the time to first Symptomatic UTI, will be calculated for each subject, as measured 
from the date of the Randomization Visit (Visit 1) to the date of first 
Symptomatic/Probable UTI diagnosis post-randomization.  Kaplan-Meier life-table 
Endpoint 
Variable 
Type 
Statistics 
Method 
Total E. coli vaginal 
colonization  
Categorical Frequency, 
Percent 
95% confidence 
interval at Visits 
1-6 
Change in vaginal 
microbiota (DNA 
Amplification) 
Categorical Frequency, 
Percent 
CMH 
95% confidence 
interval 
H2O2, lactic acid, 
cytokines 
Numeric 
Medians, 
Percentiles 
Wilcoxon rank-
sum test 
Adverse Events, Serious 
Adverse Events, 
Symptoms, and signs of 
irritation on pelvic 
examination 
Categorical Frequency, 
Percent 
Fisher’s exact 
test may be 
used for 
selected AE 
preferred 
terms, 
symptoms or 
findings 

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analysis will be used to describe the survival rates and the logrank test will be used to 
compare the two treatment groups. 
 
10.10 
Analysis of Secondary Endpoints 
10.10.1 
Shifts in Vaginal Microbiota, as Assessed by Nugent score 
Significant changes in vaginal microbiota will be evaluated by the Nugent score with 
shift tables from Visit 1 (Day 1) to Visit 6.  The Nugent score is graded as 0 to 10 and 
categorized as follows: 
 
1 Normal, if between 0 and 3; 
2 Intermediate, if between 4 and 6; 
3 Bacterial vaginosis (BV), if between 7 and 10.   
 
See Appendix A, Nugent Scoring System for Gram Stained Vaginal Smears, for complete 
Nugent scoring criteria.  
 
The following shift table will be used to summarize the change in Nugent score from 
Visit 1 (Day 1) to Visit 6 (or final score).    
Table 2   
 
 
Nugent Score Shift Table 
 
 
Final 
Nugent 
Score 
0–3 
4–6 
³ 7 
Total 
Baseline 
Nugent 
Score 
0–3 
 
 
 
 
4–6 
 
 
 
 
³ 7 
 
 
 
 
 
Changes within each group and between groups will be reported.   
 
10.10.2 
Vaginal Colonization with Lactobacilli 
Total lactobacilli (based on culture) will be scored as 1+, 2+, 3+, or 4+.   
 
 
Colonization with L. crispatus strain CTV-05 (based on rep-PCR) will be scored as present 
or absent (frequency).  Number and percent of subjects with positive CTV-05 in each 
treatment group will be presented.  95% confidence intervals will be calculated to 
evaluate any difference between the treatment groups. 
 
The differences of these scores between Visit 1 (Day 1, Baseline) and Visits 3 and 6 for 
each subject will be evaluated within each group and between treatment groups.   

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10.10.3 
 
E. coli Vaginal Colonization  
The number (%) subjects with E. coli colonization in each treatment group will be 
summarized by treatment group and visit.  95% confidence intervals will be calculated to 
evaluate any difference between the treatment groups at a given visit.   
 
10.10.4 
Change in Vaginal Microbiota, as assessed by DNA amplification. 
 
The number (%) of specific Lactobacillus spp. and uropathogens will be summarized by 
treatment group and visit.  95% confidence intervals will be calculated to evaluate any 
difference between the treatment groups at a given visit.   
 
10.10 5 
Safety and Tolerability. 
 
The safety endpoints include specific solicited adverse events (AEs), all other reported 
AEs, serious adverse events (SAEs) and signs of irritation on pelvic examination. The 
adverse events emerging during the study, their severity and relation to study product 
will be recorded.  Each event will be coded with system organ class and preferred term 
based on the Medical Dictionary for Regulatory Activities (MedDRA).  Number (%) of 
subjects with AEs will be summarized by system organ class, preferred terms, and 
treatment group.  Severity of AEs and relationship to study product will also be 
summarized by system organ class, preferred terms, and treatment group.  SAEs and 
reasons for premature termination from study will be summarized by treatment group 
in frequency and percent.  In addition, signs of irritation of the external genitalia, vagina 
or cervix from pelvic examination, along with their severity and relation to study 
product will be summarized by treatment group.  Furthermore, symptoms and physical 
findings will be summarized. 
10.10.6 
Subject Characteristics and Disposition 
The subjects’ age, weight, ethnic background, and other demographic characteristics 
will be summarized by treatment group.  All subjects who discontinue the study will be 
identified and reasons for their discontinuation will be recorded. 
 
10.10.7 
Assessment of Protocol Compliance 
Every attempt will be made to select subjects who are eligible and will comply with the 
protocol.  Noncompliant subjects may be discontinued from the study.  Protocol 
deviations will be listed and summarized by treatment arm.  

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11  
RISKS AND DISCOMFORTS TO STUDY SUBJECTS  
11.1  
LACTIN-V and Placebo Applicator Users  
11.1.1 
Risks 
 
The potential risks of LACTIN-V are currently unknown.  Pelvic examinations and 
analyses of vaginal discharge and vaginal microbiota were included in the Phase 1 
studies designed to assess LACTIN-V’s safety and colonization.  The initial Phase 1 safety 
study of LACTIN-V in healthy women, Protocol LV-001, included colposcopy to evaluate 
for inflammation or other lesions of the vaginal, cervical or vulvar epithelium.  There 
were no significant differences noted in these safety parameters between treated 
subjects and those who remained untreated or received the placebo capsule (Osel, Inc., 
personal communication). 
 
Risks from the administration of LACTIN-V are low since colonization with this type of 
organism is strongly associated with improved vaginal health.  No systemic risks are 
anticipated, since this is an organism that is applied topically, and thus not absorbed.  
These risks will be explained in the written informed consent form.  Pregnant women, 
fetuses, prisoners, children, persons with or at risk of STD or women undergoing in vitro 
fertilization will not be included in this study. 
 
Potential risks to subjects participating in this study include genital or vaginal irritation 
or symptoms.  In the initial Phase 1 study of LACTIN-V (LV-001), the following adverse 
events were experienced in (at least two) more LACTIN-V treated subjects when the 
treated groups were compared to the placebo and untreated groups: vaginal discharge, 
abdominal pain, genital pruritis, vaginal odor, vaginal burning sensation, vaginal 
candidiasis and diarrhea (Osel, Inc., personal communication).  There is also the risk of 
an allergic reaction to the latex in the condoms provided to subjects who are unaware 
of their latex allergy and who use these condoms.   
 
11.1.2 
Benefits  
Research subjects, whether they receive LACTIN-V or placebo, will have the benefit of 
an office visit and urine culture, often omitted for this condition.   Subjects will also have 
the benefit of having a pap smear.  In addition, subjects participating in this clinical trial 
may contribute to the body of knowledge in the field of preventing recurrent urinary 
tract infections. 
 
11.1.3 
Procedures for Minimizing Potential Risks 
Allergic Reactions (including anaphylaxis): A study subject with a known allergy to 
components of the capsule will be excluded from enrollment.  If an allergy or sensitivity 

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occurs during the course of the study, the study subject will be advised to immediately 
discontinue product use and seek medical attention. This event will be recorded on an 
Adverse Event (AE) Form. 
Allergies to Latex: Subjects with known allergy to latex will be provided with non-latex 
condoms. 
11.1.4 
Compare Potential Benefits with Potential Risks 
The potential benefits to women with a history of recurrent UTI will depend on the 
outcome of the study.  The subjects in this study will have the benefit of a pap smear, 
urine culture, and several pelvic examinations.  These procedures may detect underlying 
diseases sooner. 
 
11.1.5 
Costs and Compensation 
The subjects will not be charged for any of the study visits, study supplies or 
examinations. Subjects will be reimbursed for study participation to cover 
inconvenience, travel, parking and time off work. The visits will be prorated and partial 
payment given in the event that the subject only completes a portion of the study.  The 
subject will be responsible for any medical care related to pregnancy that occurs during 
study participation.  If a subject is diagnosed with a recurrence of UTI, vaginal 
candidiasis, BV, STD or other infection during this study, the subject will be responsible 
for the cost of any treatment not provided by the study site or covered by their 
insurance.   
 
12 
REFERENCES 
 
1. 
Foxman B, Barlow R, D'Arcy H, Gillespie B, Sobel JD. Urinary tract infection. self-
reported incidence and associated costs. Ann Epidemiol. 2000;10(8):509-15. 
2. 
Gupta K, Scholes D, Stamm WE. Increasing prevalence of antimicrobial resistance 
among uropathogens causing acute uncomplicated cystitis in women. JAMA. 1999 Feb 
24;281(8):736-8. 
3. 
Hooton TM, Scholes D, Gupta K, Stapleton AE, Roberts PL, Stamm WE. 
Amoxicillin-clavulanate vs ciprofloxacin for the treatment of uncomplicated cystitis in 
women: a randomized trial. JAMA. 2005 Feb 23;293(8):949-55. 
4. 
Reid G, Bruce AW, Fraser N, Heinemann C, Owen J, Henning B. Oral probiotics 
can resolve urogenital infections. FEMS Immunol Med Microbiol. 2001;30(1):49-52. 
5. 
Stamey TA, Sexton CC. The role of vaginal colonization with Enterobacteriaceae 
in recurrent urinary tract infections. J Urol. 1975;113:214-7. 
6. 
Hooton T. The vaginal flora and urinary tract infection. In: Mobley HLT, editor. 
Urinary Tract Infections: Molecular Pathogenesis and Clinical Management. Washington, 
DC: ASM Press; 1996. 

Protocol No. UW/LB-002 
 
LACTIN-V 
Original Protocol 
CONFIDENTIAL 
Page 47 of 61  
of 
 
7. 
Antonio MA, Hawes SE, Hillier SL. The identification of vaginal Lactobacillus 
species and the demographic and microbiologic characteristics of women colonized by 
these species. J Infect Dis. 1999;180(6):1950-6. 
8. 
Osset J, Bartolome RM, Garcia E, Andreu A. Assessment of the capacity of 
Lactobacillus to inhibit the growth of uropathogens and block their adhesion to vaginal 
epithelial cells. J Infect Dis. 2001;183(3):485-91. 
9. 
Kwok L, Stapleton AE, Stamm WE, Hillier SL, Wobbe CL, Gupta K. Adherence of 
Lactobacillus crispatus to vaginal epithelial cells from women with or without a history 
of recurrent urinary tract infection. J Urol. 2006 Nov;176(5):2050-4; discussion 4. 
10. 
Giorgi A, Torriani S, Dellaglio F, Bo G, Stola E, Bernuzzi L. Identification of vaginal 
lactobacilli from asymptomatic women. Microbiologica 1987 Oct;10(4):377-84. 
11. 
Antonio MA, Hillier SL. DNA fingerprinting of Lactobacillus crispatus strain CTV-
05 by repetitive element sequence-based PCR analysis in a pilot study of vaginal 
colonization. J Clin Microbiol. 2003 May;41(5):1881-7. 
12. 
Czaja CA, Stapleton AE, Yarova-Yarovaya Y, Stamm WE. Phase I trial of a 
Lactobacillus crispatus vaginal suppository for prevention of recurrent urinary tract 
infection in women. Infect Dis Obstet Gynecol. 2007;2007:35387. 
13. 
Stapleton AE, Au-Yeung M, Hooton TM, Fredricks DN, Roberts PL, Czaja CA, et al. 
Randomized, placebo-controlled phase 2 trial of a Lactobacillus crispatus probiotic given 
intravaginally for prevention of recurrent urinary tract infection. Clin Infect Dis. 2011 
May;52(10):1212-7. 
14. 
Hemmerling A, Harrison W, Schroeder A, Park J, Korn A, Shiboski S, et al. Phase 1 
dose-ranging safety trial of Lactobacillus crispatus CTV-05 for the prevention of bacterial 
vaginosis. Sex Transm Dis. 2009 Sep;36(9):564-9. 
15. 
Ngugi BM, Hemmerling A, Bukusi EA, Kikuvi G, Gikunju J, Shiboski S, et al. Effects 
of bacterial vaginosis-associated bacteria and sexual intercourse on vaginal colonization 
with the probiotic Lactobacillus crispatus CTV-05. Sex Transm Dis 2011 Nov;38(11):1020-
7. 
16. 
Hemmerling A, Harrison W, Schroeder A, Park J, Korn A, Shiboski S, et al. Phase 
2a study assessing colonization efficiency, safety, and acceptability of Lactobacillus 
crispatus CTV-05 in women with bacterial vaginosis. Sex Transm Dis. 2010 
Dec;37(12):745-50. 
17. 
Czaja CA, Stamm WE, Stapleton AE, Roberts PL, Hawn TR, Scholes D, et al. 
Prospective cohort study of microbial and inflammatory events immediately preceding 
Escherichia coli recurrent urinary tract infection in women. J Infect Dis. 2009 Aug 
15;200(4):528-36. 
 
 
 

Protocol No. LB-002 
 
LACTIN-V 
Original Protocol 
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Page 48 of 61  
 
STUDY PROCEDURES FLOW CHART 
 
Visit 0 
Screening 
Visit 
Visit 1 
Randomize 
3-10 days 
Post abx 
treatment 
Visit 2 
Week 3 
Visit 3 
Week 6 
Visit 4 
Week 10 
Visit 5 
Week 14 
Visit 6 
Week 18 
Study 
Treatment 
(LACTIN-V or 
placebo) 
 
      1 applicator qd x 5d then q week x 10 weeks 
 
 
Informed 
consent 
X 
 
 
 
 
 
 
Clean catch 
urine, dipstick, 
hemacytometer 
X 
X 
X 
X 
X 
X 
X 
Clean catch 
Urine culture 
X 
X 
X 
X 
X 
X 
X 
Urine 
pregnancy test 
 
X 
 
 
 
 
X 
Eligibility and 
medical history 
X 
X 
 
 
 
 
 
Concomitant 
Medications  
X 
X 
X 
X 
X 
X 
X 
Vital signs 
X 
 
 
 
 
 
 
Physical Exam 
X 
 
 
 
 
 
 
Pelvic 
examination 
 
X 
 
 
 
 
X 
Vaginal swab 
for pH, KOH 
(yeast) and wet 
mount (clue 
cells, 
trichomonas, 
amine test)  
X 
X 
X 
X 
X 
X 
X 
Vaginal swab 
for Gram stain  
X 
X 
X 
X 
X 
X 
X 
Vaginal swab 
for Lactobacillus 
and E. coli 
X 
X 
X 
X 
X 
X 
X 

Protocol No. LB-002 
 
LACTIN-V 
Original Protocol 
CONFIDENTIAL 
Page 49 of 61  
 
 
Visit 0 
Screening 
Visit 
Visit 1 
Randomize 
3-10 days 
Post abx 
treatment 
Visit 2 
Week 3 
Visit 3 
Week 6 
Visit 4 
Week 10 
Visit 5 
Week 14 
Visit 6 
Week 18 
Culture and 
CTV-05 rep-PCR 
Vaginal swab 
stored for DNA 
amplification of 
vaginal 
microbiota3 
X 
X 
X 
X 
X 
X 
X 
Dispense  Study 
Diary 
 
X 
X 
X 
X 
X 
X 
Review Study 
Diary 
 
 
X 
X 
X 
X 
X 
Dispense study 
medication; 
subject inserts 
1st applicator 
 
X 
 
 
 
 
 
Dispense 
condoms 
 
X 
 
 
 
 
 
Safety 
assessment 
 
 
X 
X 
X 
X 
X 
 
 
 

Protocol No. LB-002 
 
LACTIN-V 
Original Protocol 
CONFIDENTIAL 
Page 50 of 61  
 
APPENDICES 
 
Appendix A  Nugent Scoring System for Gram Stained Vaginal Smears 
 
Appendix B 
 Instructions 
 
Appendix C 
Diary 
 
 
 

Protocol No. LB-002 
 
LACTIN-V 
Original Protocol 
CONFIDENTIAL 
Page 51 of 61  
 
Appendix A 
 
Nugent Scoring System for Gram Stained Vaginal Smears 
 
The Nugent scoring system uses a 0- to 4-point scale for the evaluation of the vaginal 
microbiota and is based on the weighted sum of the following three bacterial morphotype 
scores calculated from slide exam under oil immersion (1000X): 
 
• 
Lactobacillus: large Gram-positive rods 
• 
Gardnerella/Bacteroides spp.: small Gram-variable coccobacilli/small Gram-
positive rods 
• 
Mobiluncus spp.: thin, curved Gram-variable rods 
 
The criterion for bacterial vaginosis according to Nugent’s criteria is a total score of 7 or 
more with a score of 4 to 6 being considered intermediate and a score of 0 to 3 being 
considered normal.   
 
 
Nugent Scoring System for Gram’s Stained Vaginal Smears1 
 
SCORE2 
Lactobacillus 
morphotypes 
Gardnerella/Bacteroides 
spp. morphotypes 
Curved Gram-
variable rods 
0 
4+3 
0 
0 
1 
3+ 
1+ 
1+ or 2+ 
2 
2+ 
2+ 
3+ or 4+ 
3 
1+ 
3+ 
 
4 
0 
4+ 
 
1 Source: Draft Guidance for Industry: Bacterial Vaginosis – Developing Antimicrobial 
Drugs for Treatment (July 1998) 
2 Morphotypes are scored as the average number seen per oil immersion field 
(minimum of 10–20 fields should be examined).  Each morphotype is then given a 
score form the left hand column.  The TOTAL SCORE is calculated by adding up the 
individual morphotype scores = Lactobacillus + Gardnerella/Bacteroides + curved 
Gram-negative rods. 
3 QUANTIFICATION SCALE: 0 = no morphotypes seen; 1+ = < 1 morphotype per field; 2+ 
= 1 to 4 morphotypes; 3+ = 5 to 30 morphotypes; 4+ = > 30 morphotypes per field. 

Protocol No. LB-002 
 
LACTIN-V 
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Page 52 of 61  
 
Appendix B 
Study Diary Instructions 
 
The “Diary” on the other side will help you to record when you insert your study 
applicators.  Please mark the daily boxes to record any activity or symptoms.  
 
When to Insert the Study Applicator 
    You will use the first applicator in the clinic on Day 1. All other applicators will be used 
at bedtime. 
    Starting tomorrow evening, you will insert an applicator at bedtime. Continue using one 
applicator a day at bedtime.  For the first week, you will be inserting an applicator daily 
for 5 days. In the following weeks, it will be done once a week.  The study staff will mark 
your diary for the recommended SCHEDULED DATE. 
    If you forget to insert the applicator please insert it as soon as you remember.   
Recording When You Insert the Study Applicator: Use the Diary on the Other Side 
        Write the date and time in the Diary box for each applicator that you insert (Dose 1, 
Dose 2, etc.).  If you insert your applicator after midnight, record the actual date and time 
of insertion.  
 Recording Activity 
Check the box for each day on which an activity occurred. 
Recording Symptoms 
 
Write 1=Mild, 2=Moderate or 3=Severe in the box for each symptom you have 
during the first 7 days of the study.  
To Insert A An Applicator 
 
 
Wash your hands thoroughly with warm water and soap. 
 
Open one applicator package. Do not use anything sharp, like scissors, which could 
damage the applicator. 
 
Holding the applicator between your thumb and fingers, insert into the opening of 
the vagina (like a tampon), and push plunger to dispense the contents. 
Storage and General Instructions 
Store the applicators in their box at room temperature until use.  
Please avoid having sexual intercourse for 24 hours after use or use the condoms provided 
by the study. 
Do not use another vaginal product, such as contraceptive creams, gels, foams, sponges, 
lubricants, douches, etc. during this study unless your doctor prescribes it.  

Protocol No. LB-002 
 
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Page 53 of 61  
 
Do not use tampons for 24 hours after applicator use. 
Do not insert the applicator if you are having heavy bleeding from your period.   
If you lose or damage an applicator, use another instead.  If you somehow lose or damage 
more than 2 applicators or the whole box, please call the study clinic immediately for 
further instructions.  
 
Place used applicators back in their original pouches and return at clinic visits, and 
return any unused applicators at the end of the study. 
 
 
 
Appendix C 
 
Study Diary: see attached