A Double-blinded, Randomized, Placebo-controlled, Parallel-group Study Evaluating the Effect of the Probiotic on Recurrent Urinary Tract Infection (UTI) in Adult Women Recently Treated for UTI.
Phase: NA
Conditions: Recurrent Urinary Tract Infection in Adult Women
Sponsor: BioGaia AB

 
 
Clinical Study Protocol 
 
 
A double-blinded, randomized, placebo-controlled, parallel-
group study evaluating the effect of the probiotic Lactobacillus 
reuteri on recurrent urinary tract infection (UTI) in adult women 
recently treated for UTI. 
 
Sponsors study code: CSUB0144 
NCT 03366077 
Document Date: 24 Oct 2017 
 
 
 
 
 
 
 
 
 
 
 
 
 

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6 
Clinical Study Protocol 
 
 
Test Product 
Lactobacillus reuteri 
 
Study code 
BioGaia CSUB 0144 
 
Protocol Version and date 
Final; V.1.0, 2017-10-24 
 
STUDY TITLE 
A double-blinded, randomized, placebo-controlled, parallel-group study evaluating the effect of the 
probiotic Lactobacillus reuteri on recurrent urinary tract infection (UTI) in adult women recently treated 
for UTI. 
 
 
Test product and dosage 
Once daily oral administration of a combination of two          
L. reuteri strains (DSM 16666 and DSM 17938) 
 
 
Comparator product and dosage 
Placebo, once daily oral administration  
 
 
Duration of intervention 
Three months (90 days) 
 
Sponsor signatory 
Kerstin Nilsson 
BioGaia AB 
Kungsbroplan 3 
SE-112 27 Stockholm, Sweden                                                   
Phone: +46 73 439 7080 
E-mail: kn@biogaia.se 
 
 
Principal Investigator 
Erik Rein-Hedin 
Phone: +46 70 755 20 89 
E-mail: erik.hedin@ctc-ab.se 
 
 
Clinical study conduct and 
management 
CTC Clinical Trial Consultants AB 
Dag Hammarskjölds väg 13 
SE-752 37 Uppsala, Sweden 
 
 
 
 
 
 

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The following amendments have been made to the Final Clinical Study Protocol Version 1.0: 
Amendment No. 
Date of Amendment 
Revised protocol version 
Not applicable 
Not applicable 
Not applicable 
 

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2 
STUDY SYNOPSIS 
Study Title 
A double-blinded, randomized, placebo-controlled, parallel-group study evaluating the effect of the 
probiotic Lactobacillus reuteri on recurrent urinary tract infection (UTI) in adult women recently 
treated for UTI. 
Study code 
BioGaia CSUB 0144 
Study period 
Estimated date of first subject enrolled: Q4 2017 
Estimated date of last subject completed: Q4 2018 
 
Principal Investigator 
Erik Rein-Hedin, CTC Clinical Trial Consultants AB (CTC AB), Uppsala, Sweden 
 
Study design 
A double-blinded, randomized, placebo-controlled, parallel-group study. 
Objectives 
Primary objective 
The primary objective is to evaluate the effect of oral supplementation with Lactobacillus reuteri on 
the frequency of confirmed UTI during six months from start of intervention in adult women with 
recurrent UTI. 
Primary endpoint 
Mean number of confirmed UTIs during six months from start of intervention, as compared to 
placebo. 
Secondary objectives 
1. To evaluate the effect of oral supplementation with Lactobacillus reuteri on the frequency of 
confirmed UTI during the three months´ intervention period and during the three months’ 
follow-up period, respectively. 
2. To evaluate the effect of oral supplementation with Lactobacillus reuteri on time to first 
relapse of UTI. 
3. To evaluate the effect of oral supplementation with Lactobacillus reuteri on relapse rate at 
three and six months after start of intervention. 
4. To assess the tolerability of oral supplementation with Lactobacillus reuteri in adult women 
with recurrent UTI. 
Secondary endpoints 
− 
Mean number of confirmed UTIs during the three months’ intervention period, as 
compared to placebo. 
− 
Mean number of confirmed UTIs during the three months’ follow-up period, as 
compared to placebo. 
− 
Mean time from start of intervention to first relapse of UTI, as compared to placebo. 

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− 
Proportion of subjects (%) who experienced at least one confirmed UTI during three 
months from start of intervention, as compared to placebo. 
− 
Proportion of subjects (%) who experienced at least one confirmed UTI during six 
months from start of intervention, as compared to placebo. 
− 
Occurrence and frequency of Adverse Events (AEs). 
Number of subjects planned 
A total of 140 subjects completed will be required, 70 in each intervention arm.  
Diagnosis and main eligibility criteria 
Female subjects 18-50 years of age with recurrent UTI and currently on antibiotic treatment for UTI 
will be considered for participation in the study. Recurrent UTI is defined as occurrence of at least 
two UTIs during the last six months or at least three UTIs during the last 12 months with a minimum 
period of two weeks between episodes, unless there is a urinary culture confirming two different 
pathogens. 
Methodology 
The study will consist of a combined screening and randomization assessment, an IP first dose 
confirmation call and monthly follow up assessments for six months. The screening and 
randomization assessment will be performed as a phone call or a video-call using an e-health digital 
platform. Informed consent will be signed via Bank ID. The monthly follow-up assessments will be 
performed either as a video-call or by phone. However, physical visits to the clinic at CTC AB might 
be performed for subjects in Uppsala. 
Subjects will be recruited from advertising (e.g in social media, at pharmacies etc.). The subjects will 
contact the study site by phone or e-mail. Brief oral information about the study will be given and 
pre-defined pre-screening questions will be asked. Written information will be sent to the subjects 
qualified for screening together with instructions regarding the e-health platform and Bank ID signing 
procedures. 
During the screening and randomization assessment, full information about the study will be given 
and informed consent obtained as described in Section 13.3. Information regarding demographics, 
weight, height, medical history, UTI history, medication history, use of restricted products, and 
pregnancy will be collected and diet restrictions will be explained (see Section 10.6). Subjects will be 
screened for eligibility as per the pre-defined eligibility criteria (see Sections 10.4 and 10.5). 
Eligible and consenting subjects will be randomized to intervention with either Lactobacillus reuteri 
or placebo. The subject will be provided with Investigational Product (IP) for three months (90 days) 
and niture/Leu urine test kits. Instructions to start intake of IP as soon as the IP has been picked-up 
will be given. The subject will be contacted by study staff 1-3 days after randomization to confirm 
that first IP dose has been taken  
At the monthly assessments (video-call/phone-call or visit), the subject will be asked to answer pre-
defined questions regarding symptoms (frequency, urgency and dysuria). If two out of three 
symptoms are present a UTI is confirmed. If only one symptom is present the subject will perform a 
niture/Leu urine test at home, preferably on urine retained in the bladder for approximately 3 hrs. If 
the test is positive (one of two analyses), a UTI is confirmed and the subject is recommended to 
contact the health care system for consultation regarding antibiotic treatment. Information on AEs, 
concomitant medications, use of restricted products, pregnancy, and compliance with instructions for 
IP intake will be collected. 
An electronic diary will be used by the subject during the study period for recording of occurrence of 
UTI symptoms and sexual activity (frequency of intercourse, new partner, use of condom with 
spermicide). 

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The monthly follow-up assessment after six months will be the final study assessment. Number of 
empty sachets and any unused IP will be reported to CTC AB by the subject and documented by site 
staff on the IP accountability list. 
Investigational Products, dosage and mode of administration 
The manufacturer of the IP is Inpac in Lund AB, Lund, Sweden. 
Test product: 
Sachet 1 – instant drink: Xylitol, Monosodium Citrate, Cranberry Aroma, Cranberry Extract, Grape-
skin Extract, Xanthan Gum, Acesulfame Potassium and Zinc Gluconate. 
Sachet 2 – probiotic mix: Maltodextrin,  Lactobacillus reuteri DSM 16666 and Lactobacillus 
reuteri DSM 17938. 
Placebo: 
Sachet 1 – instant drink: Xylitol, Monosodium Citrate, Cranberry Aroma, Grape-skin Extract, 
Xanthan Gum and Acesulfame Potassium. 
Sachet 2 – maltodextrin: Maltodextrin. 
Subjects will be asked to consume the IP once per day, at approximately the same time every day. 
Both sachets should be emptied in a glass and mixed with 200 ml of cold water. 
Duration of intervention 
The IP will be taken for three months (90 days). 
Duration of subjects’ involvement in the study 
The subject will be involved in the study for six months. 
Efficacy assessments 
Information will be collected regarding: 
• 
Number of confirmed UTIs 
• 
Time from start of intervention to relapse of UTI 
Safety assessments 
• 
AE reporting 
Statistical methods 
Hypothesis: 
H0: Mean number of UTIs in Probiotic group = Mean number of UTIs in the placebo group 
H1: Mean number of UTIs in Probiotic group ≠ Mean number of UTIs in the placebo group 
The number of subjects needed to verity that the mean number of UTIs during six months for the 
probiotic will be 0.75 and for placebo 1.35 with a common standard deviation of 1.15, will be 118 
(1:1 randomization) using a significance level of 5% and a power of 80%. Assuming a drop-out rate 
of 15% a total of 140 subjects will be included. 
Data on continuous variables will be presented using summary statistics. Data will be presented in 
terms of number (N), arithmetic mean, standard deviation (SD), minimum and maximum value. 

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Categorical data will be presented as counts and percentages. Individual subject data will be listed by 
randomization number, and where applicable by assessment time. 
All statistical tests will be performed using a two-sided hypothesis with a significance level of 5%. 
For the primary efficacy endpoint, the mean number of UTIs will be analysed using analysis of 
covariance with intervention, UTI history, age and sexual activity as independent variables. No 
intervention by centre interaction will be possible to apply in this analysis. The estimated intervention 
difference will be presented by LSMeans and a 95% confidence interval. 
The Full Analysis Set (FAS) will consist of all subjects who have been randomized and received at 
least one dose of Intervention. 
The Per Protocol Set (PPS) will consist of all subjects who have been randomized, completed the 
three months of intervention period and without any major protocol deviations. All deviations will be 
presented and discussed at the clean file meeting. If the compliance with the IP regimen should be 
below 80% the subject will not be included in the PPS population. The definition of compliance is by 
calculating the number of delivered products in relation to number of unused IP as reported by the 
subject. 
A detailed Statistical Analysis Plan (SAP) will be approved and signed prior to clean file. 
 
 
 

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3 
TABLE OF CONTENTS 
2 
STUDY SYNOPSIS .................................................................................................. 3 
3 
TABLE OF CONTENTS ......................................................................................... 7 
4 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ....................... 12 
5 
IMPORTANT MEDICAL PROCEDURES TO BE FOLLOWED BY THE 
INVESTIGATOR ................................................................................................... 14 
5.1 
Overdose ............................................................................................................... 14 
6 
INVESTIGATOR(S) AND STUDY ADMINISTRATIVE STRUCTURE ....... 15 
7 
INTRODUCTION .................................................................................................. 16 
7.1 
Project background ............................................................................................. 16 
7.2 
Investigational Product ....................................................................................... 17 
7.2.1 
Product characteristics ................................................................................... 17 
7.2.2 
Clinical experience and mode of action ........................................................ 17 
7.3 
Study rationale ..................................................................................................... 18 
7.4 
Risk/benefit assessment ....................................................................................... 18 
7.4.1 
Summary of risk management ...................................................................... 18 
8 
STUDY OBJECTIVES AND ENDPOINTS ........................................................ 19 
8.1 
Primary objective ................................................................................................ 19 
8.1.1 
Primary endpoint ............................................................................................ 19 
8.2 
Secondary objectives ........................................................................................... 19 
8.2.1 
Secondary endpoints ....................................................................................... 19 
9 
INVESTIGATIONAL PLAN ................................................................................ 20 
9.1 
Overall study design and schedule of events ..................................................... 20 
9.2 
Rationale for study design and dose groups ..................................................... 23 
10 
STUDY POPULATION ......................................................................................... 23 
10.1 
Recruitment ......................................................................................................... 23 
10.2 
Screening and enrolment log .............................................................................. 23 
10.3 
Number of subjects .............................................................................................. 23 
10.4 
Inclusion criteria .................................................................................................. 23 
10.5 
Exclusion criteria ................................................................................................. 24 
10.6 
Restrictions during the study ............................................................................. 24 
10.6.1 
General restrictions ........................................................................................ 24 
10.6.2 
Prior and concomitant therapy ..................................................................... 24 
10.7 
Criteria for subject withdrawal ......................................................................... 25 

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10.7.1 
Procedures for discontinuation of a subject from the study ....................... 25 
10.7.2 
Subject replacement ....................................................................................... 25 
10.8 
Randomization ..................................................................................................... 26 
10.9 
Blinding ................................................................................................................ 26 
10.10 
Emergency decoding of blinded intervention during the study ...................... 26 
11 
INTERVENTIONS ................................................................................................ 26 
11.1 
Identity of Investigational Products .................................................................. 26 
11.1.1 
Test product .................................................................................................... 26 
11.1.2 
Placebo ............................................................................................................. 26 
11.2 
Packaging, labelling ............................................................................................. 27 
11.3 
Conditions for storage ......................................................................................... 27 
11.4 
Dispensing and accountability ............................................................................ 27 
11.5 
Administration of Investigational Product ....................................................... 27 
11.6 
Continuation of intervention with Investigational Product............................. 27 
11.7 
Compliance with the intervention ...................................................................... 27 
11.8 
Return and destruction of Investigational Product .......................................... 28 
12 
STUDY ASSESSMENTS ....................................................................................... 28 
12.1 
Recording of data ................................................................................................ 28 
12.2 
Technical tools used ............................................................................................. 28 
12.2.1 
E-Health digital platform ............................................................................... 28 
12.2.2 
ViedocMe electronic diary ............................................................................. 28 
12.3 
Demographics and other baseline characteristics ............................................ 29 
12.3.1 
Informed consent ............................................................................................ 29 
12.3.2 
Demographic information .............................................................................. 29 
12.3.3 
Weight and height ........................................................................................... 29 
12.3.4 
Medical/surgical history ................................................................................. 29 
12.3.5 
Urinary tract infection history ...................................................................... 29 
12.4 
Efficacy assessments ............................................................................................ 29 
12.4.1 
Signs of recurrent UTI ................................................................................... 29 
12.5 
Adverse Events .................................................................................................... 29 
12.5.1 
Event definitions ............................................................................................. 30 
12.5.1.1 Adverse Event ............................................................................................... 30 
12.5.1.2 Serious Adverse Event .................................................................................. 30 
12.5.1.3 Serious Adverse Reaction ............................................................................. 30 

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12.5.1.4 Suspected Unexpected Serious Adverse Reaction ........................................ 30 
12.5.2 
Adverse Event assessment definitions ........................................................... 31 
12.5.2.1 Assessment of severity/intensity ................................................................... 31 
12.5.2.2 Assessment of causal relationship ................................................................ 31 
12.5.2.3 Assessment of Outcome ................................................................................ 31 
12.5.3 
Collecting Adverse Events ............................................................................. 32 
12.5.4 
Recording Adverse Events ............................................................................. 32 
12.5.5 
Reporting Serious Adverse Events ................................................................ 32 
12.5.6 
Treatment and follow-up of Adverse Events................................................ 33 
12.6 
Appropriateness of measurements ..................................................................... 33 
13 
ETHICAL AND REGULATORY REQUIREMENTS ...................................... 33 
13.1 
Ethical conduct of the study ............................................................................... 33 
13.2 
Ethics review ........................................................................................................ 33 
13.3 
Subject information and consent ....................................................................... 33 
13.4 
Subject data protection ....................................................................................... 34 
13.5 
Changes to the approved Clinical Study Protocol ............................................ 34 
13.6 
Audits and inspections ........................................................................................ 34 
13.7 
Insurance .............................................................................................................. 35 
14 
STUDY MANAGEMENT ..................................................................................... 35 
14.1 
Training of study site personnel ......................................................................... 35 
14.2 
Clinical Monitoring ............................................................................................. 35 
14.3 
Source data document ......................................................................................... 36 
14.4 
Study agreements ................................................................................................ 36 
14.5 
Study time table and end of study ...................................................................... 36 
14.6 
Discontinuation of the study ............................................................................... 36 
14.7 
Reporting and publication .................................................................................. 36 
14.7.1 
Clinical Study Report ..................................................................................... 36 
14.7.2 
Confidentiality and ownership of study data ............................................... 37 
14.7.3 
Publication ....................................................................................................... 37 
14.8 
Archiving .............................................................................................................. 37 
15 
DATA MANAGEMENT ....................................................................................... 37 
15.1 
Case Report Forms .............................................................................................. 37 
15.1.1 
ViedocTM .......................................................................................................... 37 
15.1.2 
ViedocMeTM ..................................................................................................... 37 

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15.2 
Data management plan and database design .................................................... 38 
15.2.1 
Database lock .................................................................................................. 38 
16 
STATISTICAL METHODS AND DETERMINATION OF SAMPLE SIZE . 38 
16.1 
General ................................................................................................................. 38 
16.2 
Determination of sample size .............................................................................. 39 
16.3 
Analysis data sets ................................................................................................. 39 
16.3.1 
Full Analysis Set .............................................................................................. 39 
16.3.2 
Per Protocol Set............................................................................................... 39 
16.4 
Description of study population ......................................................................... 39 
16.4.1 
Demographics and baseline data ................................................................... 39 
16.4.2 
Medical history and concomitant medications............................................. 39 
16.4.3 
UTI history ...................................................................................................... 39 
16.4.4 
Compliance with the intervention ................................................................. 39 
16.5 
Analysis of primary endpoint ............................................................................. 40 
16.6 
Analysis of secondary efficacy endpoints .......................................................... 40 
16.6.1 
Number of confirmed UTIs............................................................................ 40 
16.6.2 
Time to first relapse of UTI ........................................................................... 40 
16.6.3 
Relapse rate ..................................................................................................... 40 
16.7 
Analysis safety endpoints .................................................................................... 41 
16.7.1 
Adverse Events ................................................................................................ 41 
16.8 
Statistical/analytical issues .................................................................................. 41 
16.8.1 
Adjustments for covariates ............................................................................ 41 
16.8.2 
Handling of dropouts or missing data .......................................................... 41 
16.8.3 
Multi-centre studies ........................................................................................ 41 
16.8.4 
Multiple comparison/multiplicity .................................................................. 41 
16.8.5 
Examination of subgroups ............................................................................. 41 
16.8.6 
Interim analyses .............................................................................................. 41 
17 
APPENDICES ........................................................................................................ 42 
17.1 
Signature page ..................................................................................................... 42 
17.2 
Declaration of Helsinki ....................................................................................... 43 
18 
REFERENCES ....................................................................................................... 43 
 
 
 

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List of Tables 
Table 9.1 Schedule of events ................................................................................................. 22 
 
 
List of Figures 
Figure 9.1   Study Flow-chart ................................................................................................... 21 
 
 

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4 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
 
Abbreviation or term 
Explanation 
AE 
Adverse Event 
BMI 
Body Mass Index 
cfu 
Colony-forming units 
CTA 
Clinical Trial Agreement 
CV 
Curriculum Vitae 
DMP 
Data Management Plan 
DSM 
Deutsche Sammlung von Mikroorganismen 
DVP 
Data Validation Plan 
IEC 
Independent Ethics Committee 
eCRF 
Electronic Case Report Form 
EEA 
European Economic Area 
FAS 
Full Analysis Set 
GI 
Gastro-intestinal 
ICF 
Informed Consent Form 
IP 
Investigational Product 
N 
Number 
PAC 
Proanthocyanidin 
PPS 
Per Protocol Set 
RCT 
Randomized Clinical Trials 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SAR 
Serious Adverse Reaction 
SD 
Standard Deviation 
SDV 
Source Data Verification 
SOP 
Standard Operating Procedures 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TMF 
Trial Master File 
UTI 
Urinary Tract Infection 
 
 
Enrolled subject 
Subject who has signed the Informed Consent Form (ICF) 
Screening failure 
Enrolled subject not included 

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Included subject 
Subject randomized 
Withdrawn subject 
Subject randomized but not completed 
Completed subject 
Subject completed both the intervention and the follow-up 
periods 
 
 
 

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5 
IMPORTANT MEDICAL PROCEDURES TO BE FOLLOWED BY THE 
INVESTIGATOR 
The Principal Investigator is responsible for ensuring that procedures and expertise are 
available to handle medical emergencies during the study. A medical emergency usually 
constitutes a Serious Adverse Event (SAE) and is to be reported as such. 
In the case of a medical emergency the Investigator may contact the Medical Responsible 
Person at BioGaia AB: 
Name 
Function in the study 
Telephone number and e-mail 
Kerstin Nilsson 
Sponsor’s Project Manager 
+46 73 439 7080 
kn@biogaia.se 
5.1 
Overdose 
An overdose is a dose in excess of the dose specified in this Clinical Study Protocol. Within 
the field of probiotics, an overdose in a healthy subject is not considered to be associated with 
any safety issues. 

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6 
INVESTIGATOR(S) AND STUDY ADMINISTRATIVE STRUCTURE 
This clinical study is sponsored by BioGaia AB and will be conducted by CTC Clinical Trial 
Consultants AB (CTC AB) in Uppsala, Sweden. Clinical conduct and management, 
monitoring, data management, biostatistics and medical writing will be provided by CTC AB. 
Key members of the Sponsor and CTC AB project teams and sub-contractors are presented 
below. 
 
Sponsor 
Project Manager 
Kerstin Nilsson 
Phone: +46 73 439 7080 
E-mail: kn@biogaia.se 
BioGaia AB 
Kungsbroplan 3 
SE-112 27 Stockholm, Sweden 
 
 
Clinical conduct and management, 
monitoring, data management, 
biostatistics, and medical writing 
CTC Clinical Trial Consultants AB 
Dag Hammarskjölds väg 13 
SE-752 37 Uppsala, Sweden 
Project Manager 
Anna Stendahl 
Phone: +46 738 66 48 87 
E-mail: anna.stendahl@ctc-ab.se 
 
Principal Investigator 
 
Erik Rein-Hedin 
Phone: +46 70 755 20 89 
E-mail: erik.rein-hedin@ctc-ab.se 
 
 
 
Biostatistician 
 
Fredrik Hansson, MSc 
Phone: +46 721 93 55 01 
E-mail: fredrik.hansson@ctc-ab.se 
 
 
Manufacturer of IP, labelling 
 
Inpac i Lund AB 
Åldermansgatan 2 
SE-227 64 Lund, Sweden. 
 
 
 
 
Signatures required are provided in Appendix 17.1. 

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7 
INTRODUCTION 
7.1 
Project background 
Urinary tract infections (UTIs) are the most common bacterial infections in women, with 
about 50% of women experiencing at least one UTI in their lifetime (1). Studies have shown 
that an UTI leads to an average of 1.2 days off work (2) and the Swedish Medical Products 
Agency estimates that, in Sweden, UTI cost 254 million SEK annually (3). UTIs are usually 
categorized by infection site and can additionally be classified according to whether they are 
uncomplicated (occurring in the normal urinary tract of immunocompetent individuals, 
usually young healthy non-pregnant women) or complicated (occurring in individuals of all 
ages and sexes that are immunocompromised or have genitourinary tracts with structural or 
functional abnormalities, including urethral catheterisation) (4). 
Most UTIs are acute uncomplicated cystitis caused by E. coli (86%), a gram-negative 
bacterium that is the major source of domestic and hospital infections (5). Identifiers of acute 
uncomplicated cystitis are frequency (frequent voiding of urine), urgency (the urge to void 
immediately), and dysuria (pain in voiding and the absence of both fever combined with flank 
pain and unusual vaginal discharge) in an immunocompetent woman of childbearing age who 
has no comorbidities or urological abnormalities (6). Sometimes haematuria can occur; 
suprapubic discomfort is less common. 
From an epidemiological point of view, infections of the urinary tract and bladder are more 
common in women than in men (5). About 4% of women in early adulthood experience 
bacteriuria and this incidence increases by about 1% to 2% per decade of age (7). The 
prevalence of bacteriuria in hospitalized patients increases. In contrast, patients presenting 
typical UTI symptoms combined with vaginal discharge or irritation have a decreased risk of 
an uncomplicated UTI (8). Most uropathogens originate in the rectal flora and enter the bladder 
via the urethra with an interim phase of periurethral and vaginal colonization, and sometimes 
they may reach the kidneys (9,10). 
The main pharmacological treatments of cystitis usually involve the use of antibiotics, in 
particular pivmecillinam, nitrofurantoin or trimethoprim (11, 12). Quinolones (such as 
ciprofloxacin and levofloxacin), fosfomycin, second-generation and third-generation 
cephalosporins, and b-lactam antibiotics associated with b-lactamase inhibitors (13) may also 
be used. Because of the formation of bacterial biofilms, unfortunately, the results of antibiotic 
treatment are often not satisfying. In fact, the infection is not always eradicated and 
bacteriuria and recurrences may persist (14, 15). Additionally, the inadequate use of antibiotics 
in terms of type and duration has been a common practice, generating a continuous increase in 
bacterial resistance and diverse complications associated to with this indiscriminate use (16). 
As alternatives or in addition to traditional treatments, there are some natural ingredients with 
a recognized effectiveness in counteracting the onset, persistence, or propagation of a UTI 
caused by E. coli. One example is the use of a dry extract of cranberry (Vacciunium 
macrocarpon), which is able to establish a natural physical-mechanical contrast against the 
adhesion of E. coli to the surface of the epithelial cells of the bladder and urinary tract (17). Its 
main activity is related to the proanthocyanidin (PAC) fraction containing oligomers that 
compete with the adhesions located on type-P fimbriae (FimH, mannose-sensitive) used by   
E. coli to mediate its anchorage to the epithelial cells (18). The profile of cranberry bioactives 
is distinct from that of other berry fruits, as they are rich in A-type PACs in contrast to the B-

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type PACs present in most other fruit (19). However, clinical studies of prevention of UTI 
using cranberry substances are contradictory (as reviewed by Liska, et al 2016) (20). 
A recent Cochrane review included nine randomized clinical trials (RCTs) using probiotics to 
prevent recurrent UTIs. The authors found that there was insufficient evidence to determine if 
probiotics prevented UTI recurrence. The strains of lactobacteria varied between the included 
studies. The route of delivery and duration differed and Adverse Events (AEs) were either not 
reported or poorly reported. There were only six studies comparing probiotics and placebo of 
which only three included patients treated with antibiotics before inclusion (21, 22, 23). None of 
the six studies investigated time to relapse. The authors conclude that further studies on effect 
of probiotics and AEs are needed 
Very few studies have examined treatment effect (24, 25), of which only one is a recent pilot 
study demonstrating the effect of probiotics as treatment of women with UTI (24). In this 
prospective pilot study, 33 premenopausal, non-pregnant women diagnosed with acute 
uncomplicated cystitis were enrolled and completed the treatment protocol. Women were 
instructed to take two doses of a substance containing lactobacteria and cranberry extract per 
day during the first month, and then to continue with one sachet per day until the sixtieth day. 
Nitrites and leukocyte esterase on urine dipstick testing were used as indicators of cystitis, 
with analysis performed at enrolment, after 30 and 60 days, and after one month of follow-up. 
Typical UTI symptoms, namely dysuria, frequent voiding of small volumes, urinary urgency, 
suprapubic pain, and gross haematuria were scored 0-3 and evaluated at each visit. Positive 
results for the presence of nitrites and leukocyte esterase were found in 14 and 20 subjects 
after 30 days and in nine and 14 women after 60 days, respectively (P<0.001). At the end of 
the follow-up period, positive results for nitrites and leukocyte esterase were recorded in only 
four and three of 24 and 19 subjects (16.7%, P=0.103; 15.8%, P=0.325, respectively), with 
negative results after 60 days. Typical symptoms of cystitis, specifically dysuria, frequent 
voiding, urgency, and suprapubic pain were significantly improved as well. No significant 
differences were recorded in the incidence and severity of haematuria at any visit. 
7.2 
Investigational Product 
7.2.1 Product characteristics 
Lactobacillus reuteri bacteria are active and multiply along the entire digestive tract and in 
addition, it has been shown that orally administered L. reuteri after the passage of the gastro-
intestinal (GI) tract can colonise the vagina and by that modulate the vaginal microbiota in a 
positive manner (25, 26, 27, 28, 29, 30). 
The Investigational Product (IP) consists of a combination of two L. reuteri strains: DSM 
16666 and DSM 17938 (5x108 colony forming units [cfu]). The dose has been defined based 
on data from clinical trials performed with the two individual strains (see Section 7.2.2). 
7.2.2 Clinical experience and mode of action 
L. reuteri DSM 16666 is identical to RC-14 that together with L. rhamnosus GR-1 is found in 
the product Urex. This combination of strains has been evaluated in a number of clinical 
trials, using either orally or vaginally administered bacteria. The strain can colonize the 
vagina after oral intake and it has been shown that it could be recovered from the vagina in 9 
out of 10 patients ingesting the bacteria (25). In another study, the strain was shown to persist 
in the vaginal tract for more than 19 days after administration (26). 

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Studies with oral intake of the bacteria show that the product can modulate the vaginal 
microbiota in a positive manner, and, by that, counteract UTIs and bacterial vaginosis (27, 28, 29, 
30). The strain was originally isolated from the vagina of a healthy woman and has shown 
inhibitory effects on pathogens, probably due to the production of lactic acid and hydrogen 
peroxide (31, 32). Furthermore, it prevents in vitro adhesion of uropathogens (33) and disrupts the 
biofilm produced by the vaginal pathogen Gardnerella (34). 
L. reuteri DSM 17938 is one of the most studied probiotic bacteria and has an impressive 
track record. Several studies have been performed with DSM 17938 or its mother strain 
ATCC 55730* on adults (35, 36, 37) or infants (38, 39, 40, 41, 42, 43, 50, 51). 
It was originally isolated from mother milk and has been shown to be very effective within 
the gastrointestinal tract. However, it does belong to a type of L. reuteri that often is found in 
the vagina. Thus, it represents a type of L. reuteri that is adapted to all these niches and likely 
will have a good persistence in the vagina. 
The mode of action of the strain is thought to be: (i) survival of the GI tract passage (44); (ii) 
adhesion to the vaginal mucosa similarly to the intestinal mucosa (45); (iii) inhibiting 
pathogens and modulate the vaginal microbiota by production of the broad spectrum 
antimicrobial substance reuterin (44, 46). Though, this strain produces hydrogen peroxide reuteri 
is thought to be the major antimicrobial compound; (iv) improving the mucosal integrity and 
by maintaining a functional barrier (47, 48) and (v) modulate the immune system to be more 
responsive to pathogens (49). 
7.3 
Study rationale 
Urinary tract infections are the most common bacterial infections in women and are quite 
costly for society. Unrecognized or inadequately treated infections are associated with 
recurrent UTI which deteriorate quality of life. Additionally, there is an increasing problem 
with antibiotic resistance so both alternative and preventative treatments are needed. 
One promising alternative to antibiotics are probiotics. As yet, there are too few randomized 
control studies of the efficacy of probiotics in prevention of UTIs to determine if probiotics 
are effective. Very few studies have examined treatment effect. To our knowledge, this will 
be the first RCT studying the prevention effect of the combination L. reuteri DSM 16666 and 
L. reuteri DSM 17938.on UTI. Moreover, it is the first study exploring time to relapse with 
usage of lactobacteria and will contribute to the sparse knowledge about the efficacy of 
lactobacteria on the number of relapses within a given time frame. Additionally, because AEs 
have previously been poorly studied, this study will provide further information. Thus, this 
RCT will provide important evidence that might support the strategic usage of probiotics in 
UTI, which in turn, may lead to cost reductions for society and, importantly, both reduction in 
antibiotic usage and antibiotic resistance development. 
7.4 
Risk/benefit assessment 
7.4.1 Summary of risk management 
Lactobacillus reuteri probiotics are safe products that have been used for treatment and 
prevention of many types of disorders (28, 50, 51). The most common AE with a probable link to 
probiotics is the experience of flatulence that is usually restricted to the first days of 
intervention. 

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No clinical assessments will be performed in this study, thus there will be no risks associated 
with study procedures or devices. 
Any possible AEs will be assessed in the current study. 
8 
STUDY OBJECTIVES AND ENDPOINTS 
8.1 
Primary objective 
The primary objective is to evaluate the effect of oral supplementation with Lactobacillus 
reuteri on the frequency of confirmed UTI during six months from start of intervention in 
adult women with recurrent UTI. 
8.1.1 Primary endpoint 
The primary endpoint will be the mean number of confirmed UTIs during six months from 
start of intervention, as compared to placebo. 
8.2 
Secondary objectives 
1. To evaluate the effect of oral supplementation with Lactobacillus reuteri on the 
frequency of confirmed UTI during the three months´ intervention period and during 
the three months’ follow-up period, respectively. 
2. To evaluate the effect of oral supplementation with Lactobacillus reuteri on time to 
first relapse of UTI. 
3. To evaluate the effect of oral supplementation with Lactobacillus reuteri on relapse 
rate at three and six months after start of intervention. 
4. To assess the tolerability of oral supplementation with Lactobacillus reuteri in adult 
women with recurrent UTI. 
8.2.1 Secondary endpoints 
− Mean number of confirmed UTIs during the three months’ intervention period, as 
compared to placebo. 
− Mean number of confirmed UTIs during the three months’ follow-up period, as 
compared to placebo. 
− Mean time from start of intervention to first relapse of UTI, as compared to placebo. 
− Proportion of subjects (%) who experienced at least one confirmed UTI during three 
months from start of intervention, as compared to placebo. 
− Proportion of subjects (%) who experienced at least one confirmed UTI during six 
months from start of intervention, as compared to placebo. 
− Occurrence and frequency of AEs. 

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9 
INVESTIGATIONAL PLAN 
9.1 
Overall study design and schedule of events 
This will be a double-blinded, randomized, placebo-controlled, parallel-group study with the 
primary objective to evaluate the effect of oral supplementation with Lactobacillus reuteri on 
the frequency of confirmed UTI in adult women with recurrent UTIs. 
The study will consist of a combined screening and randomization assessment, an IP first dose 
confirmation call, and monthly follow up assessments for six months. The screening and 
randomization assessment will be performed as a phone call or a video-call using an e-health 
digital platform. Informed consent will be signed via Bank ID. The monthly follow-up 
assessments will be performed either as a video-call or by phone. However, physical visits to 
the clinic at CTC AB might be performed for subjects in Uppsala. 
Female subjects 18-50 years of age with recurrent UTI and currently on antibiotic treatment 
for UTI will be recruited from advertising (e.g. in social media, at pharmacies, etc.). 
Recurrent UTI is defined as occurrence of at least two UTIs during the last six months or at 
least three UTIs during the last 12 months, with a minimum period of two weeks between 
episodes, unless there is a urinary culture confirming two different pathogens. The subject 
will contact the study site by phone or e-mail. Brief oral information about the study will be 
given and pre-defined pre-screening questions will be asked. Written information will be sent 
to the subject qualified for screening together with instructions regarding the e-health 
platform and Bank ID signing procedures. 
During the screening and randomization assessment, full information about the study will be 
given and informed consent obtained as described in Section 13.3. Information regarding 
demographics, weight, height, medical history, UTI history, medication history, use of 
restricted products, and pregnancy will be collected and diet restrictions will be explained (see 
Section 10.6). Subjects will be screened for eligibility as per the pre-defined eligibility criteria 
(see Sections 10.4 and 10.5). 
Eligible and consenting subjects will be randomized to intervention with either Lactobacillus 
reuteri or placebo. The subjects will be provided with IP for three months (90 days) and 
niture/Leu urine test kits. Instructions to start intake of IP as soon as the IP has been picked-
up will be given. 
The subjects will be contacted by study staff 1-3 days after randomization to confirm that first 
IP dose has been taken.  
At the monthly assessments (video-call/phone-call or visit), the subject will be asked to 
answer pre-defined questions regarding symptoms (frequency, urgency and dysuria). If two 
out of three symptoms are present a UTI is confirmed. If only one symptom is present the 
subject will perform a niture/Leu urine test at home, preferably on urine retained in the 
bladder for approximately 3 hrs. If the test is positive (one of two analyses), a UTI is 
confirmed and the subject is recommended to contact the health care system for consultation 
regarding antibiotic treatment. Information on AEs, concomitant medications, use of restricted 
products, pregnancy, and compliance with instructions for IP intake will be collected. 
An electronic diary will be used by the subject during the study period for recording of 
occurrence of UTI symptoms and sexual activity (frequency of intercourse, new partner, use 
of condom with spermicide). 

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The monthly follow-up assessment after six months will be the final study assessment. 
Number of empty sachets and any unused IP will be reported to CTC AB by the subject and 
documented by site staff on the IP accountability list. 
The overall study design is shown in Figure 9.1. Assessments will be performed as described 
in Table 9.1. Each assessment is further described in Section 12. 
 
 
 
Figure 9.1   Study Flow-chart 
 
 
 

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Table 9.1 
Schedule of events 
 
Screen/ 
Random. 
Intervention period 
Follow-up 
Assessment number 
1 
1st dose 
2 
3 
4 
5 
6 
7 
Day 
-10 to 0 
1 
30±7 
60±7 
90+7 
120±7 
150±7 
180±7 
Informed consent 
X 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
Weight and height information 
X 
 
 
 
 
 
 
 
Medical/surgical history 
X 
 
 
 
 
 
 
 
UTI history 
X 
 
 
 
 
 
 
 
Medication/product history 
X 
 
 
 
 
 
 
 
Inclusion/exclusion criteria 
X 
 
 
 
 
 
 
 
Randomization 
X 
 
 
 
 
 
 
 
IP distribution triggered 
X 
 
 
 
 
 
 
 
Confirmation of IP first dose call 
X1 
 
 
 
 
 
 
 
IP intake 
 
X 
 
 
 
Signs of recurrent UTI 
 
 
X 
X 
X 
X 
X 
X 
AE reporting 
 
 
X 
X 
X 
X 
X 
X 
Pregnancy information 
X 
 
X 
X 
X 
X 
X 
X 
Diary recordings (ViedocMeTM)2 
 
X 
Concomitant medications/products3 
 
 
X 
X 
X 
X 
X 
X 
1 1-3 days after randomization 
2  Information on sexual activity and signs of recurrent UTI. 
3 See Section 10.6 for restricted products.

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9.2 
Rationale for study design and dose groups 
The study will be performed in female subjects aged 18-50 since this is the population 
expected to benefit from the intervention studied. 
The study structure based on assessments using video -and phone-calls to ensure access to a 
broad population in a wide area although only one study site will be involved. 
No clinical safety assessments are considered necessary considering the general good safety 
profile of probiotics. 
10 STUDY POPULATION 
10.1 Recruitment 
Study subjects will be recruited using advertisement (e.g in social media, at pharmacies etc.) 
directed to pre-defined regions surrounding a number of IP distribution points. 
10.2 Screening and enrolment log 
The Investigator will keep records of all subjects screened and included. The reason for 
screening failure should be stated for all subjects screened but not included. The reason for 
withdrawal should be stated for all subjects included but not completed. 
10.3 Number of subjects 
A total of 140 subjects completed will be required, 70 in each intervention arm.  
10.4 Inclusion criteria 
For inclusion in the study, subjects must fulfil the following criteria: 
1. Willing and able to give informed consent for participation in the study. 
2. Woman aged 18-50 years old, both inclusive, at screening. 
3. Body Mass Index (BMI) ≥18 at screening. 
4. Recurrent UTI, otherwise healthy.  Recurrent UTI is defined as occurrence of at least 
two UTIs during the last six months or at least three UTIs during the last 12 months 
with a minimum period of two weeks between episodes, unless there is urinary culture 
confirming two different pathogens. 
5. Currently on antibiotic treatment for UTI, at the time of screening 1. 
6. Able and willing to comply with the restrictions defined for the study period (see 
Section 10.6). 
 
1 The intake of IP must be started during or within five days from stop of current antibiotic treatment for UTI.  

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7. Access to Bank ID and ability to use the e-health platform (i.e. Internet access). 
8. Ability to understand and comply with the requirements of the study, as judged by the 
Investigator. 
10.5 Exclusion criteria 
Subjects must not enter the study if any of the following exclusion criteria are fulfilled: 
1. Postmenopausal (defined as 12 months of amenorrhoea). 
2. Pregnant or breastfeeding. 
3. Planning to become pregnant during the study. 
4. Irregular menstruations combined with perimenopausal symptoms. 
5. Known hypersensitivity or allergy to any of the components of the test product, or to 
the comparator (placebo). 
6. Currently on long-term antibiotic treatment. 
7. Use of spermicide contraceptives including spermicidal condom within three days 
prior to first IP dose. 
8. History of complicated cystitis, urgency incontinence, recent pyelonephritis, 
urological and/or gynaecologist abnormalities, as judged by the Investigator. 
9. Unstable bowel disorder such as chronic or recurring diarrhoea, Crohn’s disease, 
ulcerative colitis. 
10. History of any clinically significant disease or disorder which, in the opinion of the 
Investigator, may either put the subject at risk because of participation in the study, or 
influence the results or the subject’s ability to participate in the study. 
11. Participation in any other clinical interventional study within 30 days before 
treatment.  
10.6 Restrictions during the study 
10.6.1 General restrictions 
Unprotected sexual contact with new male partner will not be allowed during the study to 
avoid chlamydia symptoms being similar to UTI symptoms. 
The subject must be willing and able to comply with the instructions for storage of the IP 
given (see Section 11.3). 
10.6.2 Prior and concomitant therapy 
No probiotic food supplements, probiotic foods or fermented food other than the test product, 
including vaginal products containing Lactobacillus (including probiotic tampons) or 
affecting the pH, are allowed from screening and throughout the study period.  

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Neither is any food or food supplements containing cranberries allowed from screening and 
throughout the study period. Subjects should continue with the same general diet and 
lifestyle, except probiotic and cranberry consumption.  
Use of spermicide contraceptives including spermicidal condom will not be allowed during 
the study, up to Day 180. 
Use of oral or vaginal fungicides will not be allowed during the study, up to Day 180. If 
typical vaginal candida symptoms appear (itching and typical thick, clumpy, white vaginal 
discharge) sporadic usage of oral fluconazole 150 mg as a single dose may be allowed and 
should be noted. 
Subjects must not participate in any other clinical interventional study during the study 
period.  
Other medications considered necessary for the subject’s safety and well-being, may be used 
during the study period. In case of antibiotic use, the type and duration should be recorded. 
Any use of fluconazole, prohibited medication, therapies or products will require evaluation 
by the Investigator to determine whether or not the subject should continue in the study. This 
may be done in consultation with the Sponsor. 
10.7 Criteria for subject withdrawal 
Subjects are free to discontinue their participation in the study at any time and for whatever 
reason without affecting their right to an appropriate follow-up assessment or their future 
care. If possible, the reason for withdrawal of consent should be documented. 
Subjects may be discontinued from the study at any time at the discretion of the Investigator 
for any of the following reasons: 
• Severe non-compliance to Study Protocol procedures, as judged by the Investigator 
and/or Sponsor. 
• Subject is lost to follow-up. 
• Significant AEs posing a risk for the subject, as judged by the Investigator and/or Sponsor 
10.7.1 Procedures for discontinuation of a subject from the study 
A subject who prematurely discontinues participation in the study will always be asked about 
the reason(s) for discontinuation and the presence of any AEs. If possible, they will be 
contacted by the Investigator and assessed according to the procedures scheduled for the 
follow-up assessment, as far as possible. Any ongoing AEs will be followed as described in 
Section 12.5.6. 
All data collected until discontinuation will be used in the study. 
10.7.2 Subject replacement 
Withdrawn subjects will not be replaced. 

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10.8 Randomization 
Subjects will be randomized to treatment with active test product or placebo (1:1). A 
computer-generated randomization list will be created by CTC AB. The randomization will 
be performed using block randomization within each IP distribution site (these sites will be 
identified by the Sponsor prior to creating the randomization list). Each distribution site will 
receive pre-packed boxes with either the test product or placebo, each box marked with a 
randomization number dedicated to the subject at randomization. The clinic will have a sub-
part of the randomization list which contains information about randomization number and 
distribution site. 
10.9 Blinding 
This is a double-blinded study. All study staff, including the Principal Investigator and the 
persons performing the subject assessments using the video link or phone calls, will be 
blinded during the study. Sealed individual treatment code envelopes will be kept at the clinic 
to be able to break the code if any emergency occurs, as judged by the Investigator. 
10.10 Emergency decoding of blinded intervention during the study 
The intervention code may only be broken by the study medical staff in case of emergency 
when knowledge of the intervention received is necessary for the proper medical 
management of the subject. The code breaking procedure should be carefully documented in 
the medical records. 
11 INTERVENTIONS 
11.1 Identity of Investigational Products 
The manufacturer of the IP is Inpac in Lund AB, Lund, Sweden. The two IPs (test product 
and placebo) each contains two sachets. 
11.1.1 Test product 
Sachet 1 – instant drink: Xylitol, Monosodium Citrate, Cranberry Aroma, Cranberry Extract, 
Grape-skin Extract, Xanthan Gum, Acesulfame Potassium and Zinc Gluconate. 
Sachet 2 – probiotic mix: Maltodextrin,  Lactobacillus reuteri DSM 16666 and Lactobacillus 
reuteri DSM 17938. 
11.1.2 Placebo 
Sachet 1 – instant drink: Xylitol, Monosodium Citrate, Cranberry Aroma, Grape-skin Extract, 
Xanthan Gum and Acesulfame Potassium. 
Sachet 2 – maltodextrin: Maltodextrin. 

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11.2 Packaging, labelling 
Labels will comply with applicable Good Manufacturing Practice (GMP) requirements 
(EudraLex VOLUME 4, Good manufacturing practices, ANNEX 13, Manufacture of 
investigational medicinal, products, February 2010, section 26). 
11.3 Conditions for storage 
The IP should be stored at +2 to +8°C. Temperature control will be performed once daily at 
the distribution sites (business days only). When the IP has been distributed to the subject, it 
should be refrigerated as soon as possible and kept in the refrigerator until use. A thermal bag 
will be provided to each subject. The product can be stored in the thermal bag for a maximum 
of 12 hrs. 
11.4 Dispensing and accountability 
The IP will be picked-up by the subject at local IP distribution sites. The subject will receive 
90 packages of IP. The IP can be picked-up at several occasions, if preferred by the subject. 
At the last assessment of the intervention period (Day 90), the subject will inform CTC AB 
about the number of empty sachets and any unused IP for accountability and check of 
intervention compliance. 
Each IP distribution site will maintain an IP accountability list detailing the dates and 
quantities of the IP allocated to each subject. Clinical staff will record any unused IP on the 
IP accountability list, based on information given by the subject. 
11.5 Administration of Investigational Product 
The IP will be self-administered by the subject. Subjects will be asked to consume the IP 
(two sachets) once per day, at approximately the same time every day, for 90 days. Both 
sachets should be emptied in a glass and mixed with 200 ml of cold water. 
The intake of IP must be started during or within five days from stop of current antibiotic 
treatment for UTI. 
11.6 Continuation of intervention with Investigational Product 
There will be no intervention with the current IP available for the study subjects after end of 
study participation. 
11.7 Compliance with the intervention 
During the monthly assessments (video-calls/phone-calls or visits), the subject will be asked 
if the IP has been stored and taken according to instructions and any deviations will be 
recorded. 

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11.8 Return and destruction of Investigational Product 
Any unused IP will be destroyed by the subject and reported to the clinical staff at CTC AB 
after completion of the intervention period. The Monitor will check the IP accountability list 
to verify that all unused IP is adequately documented. 
12 STUDY ASSESSMENTS 
The study assessments are described in the sections below and the timing of these 
assessments are detailed in the schedule of events (Table 9.1, Section 9.1). 
12.1 Recording of data 
The Principal Investigator at the study site will provide the Sponsor with all data produced 
during the study from the scheduled study assessments. He/she ensures the accuracy, 
completeness, legibility, and timeliness of the data reported to Sponsor in the electronic Case 
Report Form (eCRF) and in all required reports. 
12.2 Technical tools used 
12.2.1 E-Health digital platform 
The system for electronic signature of the Informed Consent Form (ICF) using Bank-ID for 
identity authentication will be provided by Assently. The system (web interface) will be 
accessed via Internet. Signed ICF´s will be stored in Assently encrypted, secured server which 
is located in Sweden. A link to the signed ICF will be sent via email to the subject and 
responsible clinical staff. The signed ICF will be available for monitoring and auditing 
purposes, when required. 
The e-health platform for video-call (the system) will be provided by VisibaCare. The system 
(web interface) will be accessed via Internet and the subject will log-in to the system using 
Bank-ID for identity authentication. All communications during video calls are secured, 
encrypted and handled in accordance with the Data Protection law. The information will be 
stored in VisibaCare encrypted, secured server which is located in Sweden. 
A telephone call could also be used instead of video-call. The clinical personnel will ask the 
subject to identify herself by her personal identification number. 
12.2.2 ViedocMe electronic diary 
An electronic diary will be used by the subject during the study period for recording of 
occurrence of UTI symptoms and sexual activity (frequency of intercourse, new partner, use 
of condom with spermicide). 

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12.3 Demographics and other baseline characteristics 
12.3.1 Informed consent 
Informed consent must be obtained before any screening procedures are initiated. The 
informed consent will be signed via Bank ID. The informed consent procedure is further 
described in Section 13.3. 
12.3.2 Demographic information 
The following demographic data will be recorded: age, and ethnic origin. 
12.3.3 Weight and height 
Weight and height will be recorded based on information given by the subject. Body Mass 
Index will be calculated from the height and weight recorded and rounded to the nearest 
whole number. 
12.3.4 Medical/surgical history 
Medical/surgical history will be obtained during the screening interview to confirm 
eligibility. 
12.3.5 Urinary tract infection history 
Information regarding previous UTIs (diagnosis, prescriptions, etc.) during the last 12 months 
will be collected to confirm eligibility. 
12.4 Efficacy assessments 
12.4.1 Signs of recurrent UTI 
At the monthly assessments, the subjects will be asked to answer pre-defined questions 
regarding UTI symptoms:  frequency (frequent voiding of urine), urgency (the urge to void 
immediately), and dysuria (pain in voiding and the absence of both fever combined with 
flank pain and unusual vaginal discharge). If two out of three symptoms are present a UTI is 
confirmed. If only one symptom is present the subject will perform a niture/Leu urine test at 
home, preferably on urine retained in the bladder for approximately 3 hrs. If the test is 
positive (one of two analyses), a UTI is confirmed and the subject is recommended to contact 
the health care system for consultation regarding antibiotic treatment. 
12.5 Adverse Events 
In this study, the IP is a food supplement and not an investigational medicinal product. 
However, the procedures for monitoring, collecting and reporting of AEs will be the same as 
for an investigational medicinal product, as far as possible. 

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12.5.1 Event definitions 
12.5.1.1 Adverse Event 
An Adverse Event is any untoward medical occurrence in a clinical study subject 
administered an IP and which does not necessarily have a causal relationship with this 
intervention. An AE can therefore be any unfavourable and unintended sign (including a 
significant abnormal laboratory value), symptom, or disease temporally associated with the 
use of an IP, regardless of whether it is considered related to the IP. 
12.5.1.2 Serious Adverse Event 
An SAE is any AE that: 
• results in death 
• is life-threatening (this refers to an event in which the subject was at risk of death at 
the time of the event; it does not refer to an event that hypothetically might have 
caused death had it been more severe) 
• requires inpatient hospitalisation or prolongation of existing hospitalisation 
• results in persistent or significant disability/incapacity 
• is a congenital anomaly/birth defect 
• is medically important (this refers to an event that may not be immediately life-
threatening or result in death or hospitalisation, but may jeopardise the subject or 
may require intervention to prevent any of the SAEs defined above) 
 
Examples of medically important events are intensive treatment in an emergency room for 
allergic bronchospasm or blood dyscrasias, convulsions that do not result in hospitalisation, 
development of drug dependency, and drug abuse. 
Planned hospitalisations or surgical interventions for a condition that existed before the 
subject signed the ICF and that did not change in intensity are not SAEs. 
If there is any doubt as to whether an AE meets the definition of an SAE, a conservative 
viewpoint must be taken, and the AE must be reported as an SAE. 
12.5.1.3 Serious Adverse Reaction 
The term Serious Adverse Reaction (SAR) is to be used whenever either the Investigator or 
Sponsor or designee assessed the SAE as possibly or probably related to the IP. 
12.5.1.4 Suspected Unexpected Serious Adverse Reaction 
A Suspected Unexpected Serious Adverse Reaction (SUSAR) is any SAR whose nature or 
intensity is not consistent with the current product information. 

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12.5.2 Adverse Event assessment definitions 
12.5.2.1 Assessment of severity/intensity 
The Investigator must assess the severity/intensity of an AE using the following definitions, 
and record it on the Adverse Event Form in the eCRF: 
Mild 
 
The AE does not interfere in a significant manner with the subject’s 
normal functioning level. It may be an annoyance. 
Moderate 
 
The AE produces some impairment of function but not hazardous to 
health. It is uncomfortable and/or an embarrassment. 
Severe 
 
The AE produces significant impairment of functioning or incapacitation 
and/or it is a hazard to the subject. 
12.5.2.2 Assessment of causal relationship 
The Investigator must assess the causal relationship between an AE and the IP using the 
definitions below and record it on the Adverse Event Form in the eCRF as well as on the 
Serious Adverse Event Report Form, if applicable: 
• Probable – the AE has a strong temporal relationship to the IP or recurs on re-
challenge, and another aetiology is unlikely or significantly less likely. 
• Possible – the AE has a suggestive temporal relationship to the IP, and an 
alternative aetiology is equally or less likely. 
• Not related – the AE has no temporal relationship to the IP or is due to 
underlying/concurrent illness or effect of another drug (that is, there is no 
causal relationship between the IP and the AE). 
 
An AE is considered causally related to the use of the IP when the causality assessment is 
probable or possible. For an SAE, a causality assessment is also made by the Sponsor. 
12.5.2.3 Assessment of Outcome 
The Investigator must assess the outcome of an AE using the definitions below and record 
it on the Adverse Event Form in the eCRF: 
• Recovered – the subject has recovered completely, and no symptoms remain. 
• Recovering – the subject’s condition is improving, but symptoms still remain. 
• Recovered with sequelae – the subject has recovered, but some symptoms 
remain (for example, the subject had a stroke and is functioning normally, but 
has some motor impairment). 
• Not recovered – the subject’s condition has not improved and the symptoms are 
unchanged (for example, an atrial fibrillation has become chronic). 
• Death 

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12.5.3 Collecting Adverse Events 
AEs identified using any of the following methods will be recorded: 
• AEs spontaneously reported by the subject 
• AEs observed by the Investigator or medical personnel 
• AEs elicited based on non-leading questions from the Investigator or medical 
personnel 
Collection of AEs starts after the subject signs the ICF and continues until the last follow-up 
assessment. At the last follow-up assessment, information on new AEs or SAEs, if any, and 
stop dates for AEs recorded and on-going during the dosing period must be recorded. 
12.5.4 Recording Adverse Events 
Adverse Events must be recorded on an Adverse Event Form in the eCRF. The Investigator 
must provide information on the AE, preferably with a diagnosis or at least with signs and 
symptoms; start and stop dates, start and stop time; intensity; causal relationship to IP; action 
taken, and outcome. 
If the AE is serious, this must be indicated in the eCRF. Furthermore, the Investigator must 
fill out the Serious Adverse Event Report Form and report the SAE to the Sponsor as 
described in Section 12.5.5. 
AEs, including out-of-range clinically significant clinical safety laboratory values, must be 
recorded individually, except when considered manifestations of the same medical condition 
or disease state; in such cases, they must be recorded under a single diagnosis. 
If the severity/intensity of an AE increases a new Adverse Event Form must be completed in 
the eCRF. 
12.5.5 Reporting Serious Adverse Events 
The Investigator will be made aware of an SAE during the scheduled follow-up assessment 
(video-call/phone calls or visit) or in case the subject contacts the site between scheduled 
visits. From start of IP administration, all SAE must be reported to the Sponsor within 24 hrs 
of when the Investigator became aware of the SAE. The SAE should be mailed to the 
Sponsor SAE mailbox at saeclinicaltrials@biogaia.se. 
 
The same information must also be sent to CTC AB SAE email inbox: sae@ctc-ab.se 
 
To report SAEs, the Serious Adverse Event Report Form for clinical studies provided must be 
used. The first report should contain as much information as possible, and if more 
information about the subject’s condition becomes available a follow-up report must be 
submitted with the additional information using the same procedure as for the initial report. 
The Sponsor or a delegate will assume responsibility for reporting SAEs to applicable IEC in 
accordance with local regulations. 
The Sponsor will assess expectedness and inform all the Investigators about any SUSARs. 

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12.5.6 Treatment and follow-up of Adverse Events 
Subjects with AEs that occur during the study must be treated according to daily clinical 
practice at the discretion of the Investigator. 
AEs must be followed up until resolution or the final study assessment, whichever comes 
first. 
It is the responsibility of the Investigator to follow up on all SAEs until the subject has 
recovered, stabilized, or recovered with sequelae, and to report to the Sponsor all relevant 
new information using the same procedures and timelines as those for the initial report. 
Relevant information includes discharge summaries, autopsy reports, and medical 
consultation. 
SAEs spontaneously reported by a subject to the Investigator within 30 days after the last 
follow-up assessment must be handled in the same manner as SAEs occurring during the 
study. These SAEs will be reported to the Sponsor. 
12.6 Appropriateness of measurements 
The screening and randomization assessment will be performed as a phone call or a video-
call using an e-health digital platform (see Section 12.2.1) and the follow-up assessments will 
be performed either as video-calls or by phone. In case a visit to the clinic is performed for 
subjects in Uppsala, the same information will be collected as planned for the video/phone-
calls, thus no clinical assessments will be performed. 
13 ETHICAL AND REGULATORY REQUIREMENTS 
13.1 Ethical conduct of the study 
The study will be performed in accordance with ethical principles that have their origin in the 
Declaration of Helsinki (see Appendix 17.2) and applicable local regulatory requirements. 
A link to the Declaration of Helsinki is included in Appendix 17.2. 
13.2 Ethics review 
CTC AB Uppsala, on behalf of the Sponsor, is responsible for submission of the Clinical 
Study Protocol, the subject information and ICF, any other written information to be provided 
to the subjects and any advertisements used for recruitment of subjects to the applicable IEC 
for approval. Approval must be obtained in writing from IEC before the first subject can be 
recruited. 
13.3 Subject information and consent 
It is the responsibility of the Investigator or an authorised associate to give each potential 
study subject adequate verbal and written information before any study specific assessments 
are performed. Brief oral information about the study will be given during the initial pre-
screening call. Written information will be sent to the subjects qualified for screening. During 
the screening and randomization assessment, full oral information about the study will be 
given. The informed consent must be signed by the subject and by the person who conducted 

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the informed consent discussion before any study-related information is recorded or 
procedures performed (e.g. randomization, IP distribution) using Bank ID. 
The information will include the objectives and the procedures of the study as well as any 
risks or inconvenience involved. It will be emphasised that participation in the study is 
voluntary and that the subject may withdraw from participation at any time and for any 
reason, without any prejudice. All subjects will be given the opportunity to ask questions 
about the study and will be given sufficient time to consider participation before signing the 
ICF. 
The subject information including the signed ICF will be made available to the subjects via 
the e-health platform. 
Documentation of the discussion and the date of informed consent must be recorded in the 
source documentation and in the eCRF. The subject information sheet and the signed ICF 
should be filed by the Investigator for possible future audits and/or inspections. 
The final approved version of the subject information and ICF must not be changed without 
approval from the Sponsor and the applicable IEC. 
13.4 Subject data protection 
The ICF includes information that data will be recorded, collected and processed and may be 
transferred to European Economic Area (EEA) or non-EEA countries. In accordance with the 
European Union Data Protection Directive (95/46/EC [Regulation 2016/679 from 2018-05-
25]), the data will not identify any persons taking part in the study. 
The potential study subject should be informed that by signing the ICF she approves that 
authorized representatives from Sponsor, CTC AB, and the concerned IEC have direct access 
to her medical records for verification of clinical study procedures. An authorization from the 
clinic for direct access to medical records must be available. 
The subject has the right to request access to her personal data and the right to request 
rectification of any data that is not correct and/or complete. 
The Investigator must file a Subject Identification List which includes sufficient information 
to link records, i.e. the eCRF and clinical records. This list should be preserved for possible 
future inspections/audits but should not be made available to the Sponsor except for 
monitoring or auditing purposes. 
13.5 Changes to the approved Clinical Study Protocol 
Any proposed change to the approved Final Clinical Study Protocol (including appendices) 
will be documented in a written and numbered Clinical Protocol Amendment. All 
amendments including substantial changes to the protocol must be approved by the 
appropriate IEC before implementation according to applicable regulations. 
13.6 Audits and inspections 
Authorized representatives from the Sponsor or an IEC may perform audits or inspections at 
the research clinic, including Source Data Verification (SDV). The purpose of an audit or 
inspection is to systematically and independently examine all study-related activities and 

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documents, to determine whether these activities were conducted, and data were recorded, 
analysed, and accurately reported according to the protocol and any applicable regulatory 
requirements. The Principal Investigator will contact the Sponsor immediately if contacted by 
the IEC about an inspection at the site. 
13.7 Insurance 
Subjects will be covered under BioGaia AB liability insurance policy. The certificate of 
insurance and an information leaflet containing essential information about the insurance 
coverage can be provided upon request. The participating subjects are also protected in 
accordance with national regulations, as applicable. CTC AB has a company insurance 
covering services performed by CTC AB. 
14 STUDY MANAGEMENT 
14.1 Training of study site personnel 
Before enrolment of the first study subject a Sponsor representative or delegate will perform 
a Study Initiation Visit at the research site. The requirements of the Clinical Study Protocol 
and related documents will be reviewed and discussed and the investigational staff will be 
trained in any study specific procedures and system(s) utilised. 
It is the responsibility of the Investigator to ensure that all personnel involved in the study are 
fully informed of all relevant aspects of the study, and have a detailed knowledge of and 
training in the procedures that are to be executed by them. Any new information of relevance 
to the performance of this study must be forwarded to the staff involved in a timely manner. 
The Principal Investigator will keep a list of all personnel involved in the study together with 
their function and study related duties delegated. A Curriculum Vitae (CV) will be available 
for all staff delegated study-specific duties. 
14.2 Clinical Monitoring 
The study site will be periodically visited by a Monitor from an independent group at CTC 
AB at times agreed on by the Investigator and the Monitor. At the time of each monitoring 
visit, the function of the Monitor is to: 
• provide information and support to the investigational team. 
• confirm that facilities and resources remain acceptable. 
• confirm that the investigational team is adhering to the Clinical Study Protocol, 
applicable Standard Operating Procedure (SOPs), guidelines, manuals and regulatory 
requirements. 
• verify that data are being accurately and timely recorded in the eCRFs. 
• verify that data in the eCRF are consistent with the clinical records (SDV). 
• verify that the correct informed consent procedure has been adhered to for 
participating subjects. 

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• verify that AEs are recorded and reported in a timely manner and according to the 
Clinical Study Protocol. 
When the study has been completed and all queries have been resolved and the database has 
been locked, the Monitor will perform a close-out visit. 
14.3 Source data document 
A separate source data document will be generated before start of enrolment, specifying the 
location of the source of derived information appearing in the eCRF. This document must be 
signed by the Principal Investigator and the Monitor to confirm agreement before start of 
recruitment. 
The Principal Investigator should guarantee access to source documents to the Monitor and 
the IEC, if required. 
14.4 Study agreements 
The Principal Investigator must comply with all the terms, conditions, and obligations of the 
Clinical Trial Agreement (CTA) for this study. 
Agreements between Sponsor and CTC AB must be in place before any study-related 
procedures can take place, or subjects be enrolled. 
14.5 Study time table and end of study 
The end of the clinical part of the study is defined as the last follow-up assessment of the last 
subject participating in the study. 
The study is expected to start in Quarter 4, 2017 and to be completed by Quarter 4, 2018. 
14.6 Discontinuation of the study 
The Sponsor reserves the right to discontinue the study at any time, but intends only to 
exercise this right for valid scientific or administrative reasons. 
After such a decision, the Investigator must inform all participating subjects and perform 
relevant assessments, preferably according to the scheme for the final assessments. All 
delivered and unused study products and other study materials must be returned and all 
eCRFs completed as far as possible. 
14.7 Reporting and publication 
14.7.1 Clinical Study Report 
A Clinical Study Report describing the conduct of the study, the statistical analysis performed 
and the results obtained, will be prepared by CTC AB. The report will be reviewed and 
approved by, as a minimum, the Principal Investigator, the Statistician and the Sponsor. 
The final Clinical Study Report must be submitted to the IEC within 12 months after 
completion of the study. 

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14.7.2 Confidentiality and ownership of study data 
Any confidential information relating to the IP or the study, including any data and results 
from the study, will be the exclusive property of the Sponsor. The Investigator and any other 
persons involved in the study will protect the confidentiality of this proprietary information 
belonging to the Sponsor. 
14.7.3 Publication 
The results from this study will be submitted for publication at the discretion of the Sponsor. 
14.8 Archiving 
The Principal Investigator is responsible for maintaining essential documents, for 10 years 
after finalization of the Clinical Study Report. This includes any original source documents 
related to the study, the Subject Identification List (providing the sole link between named 
subject source records and anonymous CRF data), the original signed ICFs and detailed 
records of disposition of IP. 
It is the responsibility of the Sponsor to inform the Principal Investigator/institution as to 
when these documents no longer need to be retained. 
The Sponsor will archive the Trial Master File (TMF) and applicable regulatory 
requirements. 
15 DATA MANAGEMENT 
15.1 Case Report Forms 
15.1.1 ViedocTM 
Data will be collected in eCRFs (ViedocTM) specifically designed for this study. The 
Investigator or an authorized person will record subject data in the eCRF in a precise and 
accurate manner. Abbreviations should not be used. The Investigator is responsible for the 
data entered and sign off the eCRF at each visit and at the end of the study. The data should 
be recorded as soon as they are generated. Only persons authorized by the Investigator are 
allowed to make entries to the eCRF. 
An electronic diary will be used by the subject during the study period for recording of 
occurrence of UTI symptoms and sexual activity. 
15.1.2 ViedocMeTM 
An electronic diary will be used by the subject during the study period for recording of 
occurrence of UTI symptoms and sexual activity (frequency of intercourse, new partner, use 
of condom with spermicide). A separate invitation will be sent to each included subject 
directly from the ViedocTM system. The CTC AB clinic will save the sent-out invitation for 
security purpose. The invitation will consist of a URL, Username and Passcode. The subject 
will be by the system advised to change the pass code at first login. 

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15.2 Data management plan and database design 
Detailed information on data management will be described in a study-specific Data 
Management Plan (DMP). 
The person entering data into the database is not allowed to attempt any personal 
interpretation or to make any decisions on the data other than self-evident corrections as 
listed in the study-specific Data Entry Instructions or Data Handling Report. 
Data validation/data cleaning procedures are designed to assure validity and accuracy of 
clinical data. These procedures consist of manual reviewing during data entry and 
computerized edit checks and queries for identifying data values that are outside the allowed 
range, protocol violations, incomplete or inconsistent. A Data Validation Plan (DVP) will 
specify the checks that are to be performed on subject data for the study. All study-specific 
and standard data validation programming will be tested in a separate testing environment 
prior to use on production data. 
Queries in Viedoc™ can be raised by Monitors, Data Managers, medical coding team, and 
medical safety representatives. Queries raised may be related to missing or questionable data 
found during data validation, SDV, review, reconciliation of SAEs, and/or coding of study 
data. All queries should be written and answered in English. 
The Investigator or designated site personnel will provide answers to all queries by giving a 
clear explanation to the question asked. The site Monitor is responsible for approving the 
resolved query. In case the answer to a query was not satisfactory the query should be 
rejected and re-phrased if needed. Rejected queries will be re-issued automatically and listed 
as unresolved. 
15.2.1 Database lock 
When all data have been entered, discrepancies solved and all reconciliation with the SAE 
database is complete, the database will be locked and the data will be analysed. 
16 STATISTICAL METHODS AND DETERMINATION OF SAMPLE SIZE 
The principal features of the statistical analysis to be performed are described in this section. 
A more technical and detailed elaboration of the principal features will be presented in a 
separate Statistical Analysis Plan (SAP). 
16.1 General 
Data on continuous variables will be presented using summary statistics. Data will be 
presented in terms of number (N), arithmetic mean, standard deviation (SD), minimum and 
maximum value. 
Categorical data will be presented as counts and percentages. Individual subject data will be 
listed by randomization number, and where applicable by assessment time. 
All statistical tests will be performed using a two-sided hypothesis with a significance level 
of 5%. 

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16.2 Determination of sample size 
Hypothesis: 
H0: Mean number of UTIs in Probiotic group = Mean number of UTIs in the placebo group 
H1: Mean number of UTIs in Probiotic group ≠ Mean number of UTIs in the placebo group 
The number of subjects needed to verity that the mean number of UTIs during six months for 
the probiotic will be 0.75 and for placebo 1.35 with a common standard deviation of 1.15, 
will be 118 (1:1 randomization) using a significance level of 5% and a power of 80%. 
Assuming a drop-out rate of 15% a total of 140 subjects will be included. 
16.3 Analysis data sets 
16.3.1 Full Analysis Set 
The Full Analysis Set (FAS) will consist of all subjects who have been randomized and 
received at least one dose of intervention. 
16.3.2 Per Protocol Set 
The Per Protocol Set (PPS) will consist of all subjects who have been randomized, completed 
the three months of intervention period and without any major protocol deviations. All 
deviations will be presented and discussed at the clean file meeting. If the compliance with 
the IP regimen should be below 80% the subject will not be included in the PPS population. 
The definition of compliance is by calculating the number of delivered products in relation to 
the number of unused IP as reported by the subject. 
16.4 Description of study population 
16.4.1 Demographics and baseline data 
Summary statistics of demographics and other baseline characteristics will be presented by 
intervention group. 
16.4.2 Medical history and concomitant medications 
Medical/surgical history and prior/concomitant medications/products will be presented by 
descriptive statistics and listings by intervention. 
16.4.3 UTI history 
The number of previous UTIs (prior to screening) will be presented using frequency tables. 
16.4.4 Compliance with the intervention 
Compliance with the intervention will be calculated as number of delivered products divided 
by number of reported unused products and presented using summary statistics. 

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16.5 Analysis of primary endpoint 
The primary endpoint will be the mean number of confirmed UTIs during six months from 
start of intervention, as compared to placebo. 
The mean number of UTIs per intervention group will be estimated based on the total number 
of UTIs by subject. 
The mean number of UTIs will be analysed using analysis of covariance with intervention, 
UTI history, age, and sexual activity as independent variables. No intervention by centre 
interaction will be possible to apply in this analysis. The estimated intervention difference 
will be presented by LSMeans and a 95% confidence interval. 
16.6 Analysis of secondary efficacy endpoints 
16.6.1 Number of confirmed UTIs 
The number of confirmed UTIs for both the: 
− Mean number of confirmed UTIs during the three months’ intervention period, as 
compared to placebo. 
and 
− Mean number of confirmed UTIs during the three months’ follow-up period, as 
compared to placebo. 
will be analysed using the same methods as for the primary endpoint. 
16.6.2 Time to first relapse of UTI 
Time to first relapse of UTI will be defined as the time from delivery of intervention (i.e. start 
of intervention) to date of first confirmed UTI ((Confirm date – Intervention date) + 1). 
Subjects with no UTI will be censored at last known date within the study period. 
The time to first relapse will be analysed using Cox regression analysis and presented by 
Kaplan-Meier graphs. 
16.6.3 Relapse rate 
The relapse rate for both: 
− Proportion of subjects (%) who experienced at least one confirmed UTI during 
three months from start of intervention, as compared to placebo. 
and 
− Proportion of subjects (%) who experienced at least one confirmed UTI during six 
months from start of intervention, as compared to placebo. 
will be analysed using Chi-square test without continuity correction and presented using 
frequency tables. 

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16.7 Analysis safety endpoints 
16.7.1 Adverse Events 
Adverse Events and SAEs will be recorded from start of IP intervention. Medical events 
occurring between screening and start of IP intervention will be reported separately. 
16.8 Statistical/analytical issues 
16.8.1 Adjustments for covariates 
History of UTIs, age, and sexual activity will be used as covariates in the analysis of mean 
number of UTIs. 
16.8.2 Handling of dropouts or missing data 
No imputation of missing data will be performed. 
16.8.3 Multi-centre studies 
No adjustment for centre will be applied, since this will not be considered as a multi-centre 
study. 
16.8.4 Multiple comparison/multiplicity 
All statistical significant findings need to be interpreted from a medical perspective and 
judged as clinical relevant or not and therefore no adjustment for multiplicity will be 
performed. 
16.8.5 Examination of subgroups 
To be addressed in the SAP. 
16.8.6 Interim analyses 
No interim analysis will be performed. 
 
 

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17 APPENDICES 
17.1 Signature page 
 
 
“I agree to the terms of this Clinical Study Protocol.” 
 
 
Sponsor signatories 
 
 
Kerstin Nilsson 
 
 
 
 
Name 
 
Signature 
 
Date 
 
 
 
 
 
Principal Investigator 
 
 
Erik Rein-Hedin, MD 
 
 
 
 
Name 
 
Signature 
 
Date 
 
 
 
 
 

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17.2 Declaration of Helsinki 
http://www.up.ac.za/media/shared/Legacy/sitefiles/file/45/2875/declarationofhelsinki_fortaleza_brazil
2013.pdf 
 
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