Metatranscriptome analysis of the vaginal microbiota reveals potential mechanisms for protection against metronidazole in bacterial vaginosis

Bacterial vaginosis (BV) is a prevalent multifactorial disease of women in their reproductive years characterized by a shift from the Lactobacillus spp. dominated microbial community towards a taxonomically diverse anaerobic community. For unknown reasons, some women do not respond to therapy. In our recent clinical study, out of 37 women diagnosed with BV, 31 were successfully treated with metronidazole, while 6 still had BV after treatment. To discover possible reasons for the lack of response in those patients, we performed a metatranscriptome analysis of their vaginal microbiota, comparing them to patients who responded. Seven out of 8 Cas genes of Gardnerella vaginalis were highly up-regulated in non-responding patients. Cas genes, in addition to protecting against phages, might be involved in DNA repair thus mitigating the bactericidal effect of DNA damaging agents like metronidazole. In the second part of our study, we analyzed the vaginal metatranscriptomes of four patients over three months and showed high in vivo expression of genes for pore-forming toxins in L. iners and of genes encoding enzymes for the production of hydrogen peroxide and D-lactate in L. crispatus.