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Liu X, Wang M, Hu T, Lin X, Liang H, Li W, Zhao S, Zhong Y, Zhang H, Ge L, Jin X, Xiao L, Zou Y. Safety assessment of potential probiotic Lactobacillus acidophilus AM13-1 with high cholesterol-lowering capability isolated from human gut. Lett Appl Microbiol 2024; 77:ovad143. [PMID: 38126115 DOI: 10.1093/lambio/ovad143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/08/2023] [Accepted: 12/19/2023] [Indexed: 12/23/2023]
Abstract
An important risk factor for cardiovascular disease is dyslipidemia, especially abnormal cholesterol levels. The relation between probiotics and cholesterol-lowering capability has been extensively studied. Lactobacillus acidophilus plays a significant role in affecting host health, and produces multitudinous metabolites, which have prohibitory functions against pathogenic microorganisms. In this study, we identified a cholesterol-lowering strain AM13-1, isolated from a fecal sample obtained from a healthy adult male, and performed comprehensive function analysis by whole-genome analysis and in vitro experiments. Genome analyses of L. acidophilus AM13-1 revealed that carbohydrate and amino acid transport, metabolism, translation, ribosomal structure, and biogenesis are abundant categories of functional genes. No virulence factors or toxin genes with experimentally verified were found in the genome of strain AM13-1. Besides, plenty of probiotic-related genes were predicted from the L. acidophilus AM13-1 genome, such as cbh, atpA-D, and dltD, with functions related to cholesterol-lowering and acid resistance. And strain AM13-1 showed high-efficiency of bile salt hydrolase activity and the capacity for removing cholesterol with efficiency rates of 70%. These function properties indicate that strain AM13-1 can be considered as a probiotic candidate for use in food and health care products.
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Affiliation(s)
- Xudong Liu
- BGI Research, Shenzhen 518083, China
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Mengmeng Wang
- BGI Research, Shenzhen 518083, China
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Tongyuan Hu
- BGI Research, Shenzhen 518083, China
- BGI Research, Wuhan 430074, China
| | - Xiaoqian Lin
- BGI Research, Shenzhen 518083, China
- School of Bioscience and Biotechnology, South China University of Technology, Guangzhou 510006, China
| | - Hewei Liang
- BGI Research, Shenzhen 518083, China
- BGI Research, Wuhan 430074, China
| | - Wenxi Li
- BGI Research, Shenzhen 518083, China
- School of Bioscience and Biotechnology, South China University of Technology, Guangzhou 510006, China
| | | | - Yiyi Zhong
- BGI Research, Shenzhen 518083, China
- BGI Precision Nutrition, Shenzhen 518083, China
| | - Haifeng Zhang
- BGI Research, Shenzhen 518083, China
- BGI Precision Nutrition, Shenzhen 518083, China
| | - Lan Ge
- BGI Research, Shenzhen 518083, China
- BGI Precision Nutrition, Shenzhen 518083, China
| | - Xin Jin
- BGI Research, Shenzhen 518083, China
| | - Liang Xiao
- BGI Research, Shenzhen 518083, China
- BGI Research, Wuhan 430074, China
- Lars Bolund Institute of Regenerative Medicine Qingdao-Europe Advanced Institute for LifeSciences, BGI Research, Qingdao 266555, China
- Shenzhen Engineering Laboratory of Detection and Intervention of Human Intestinal Microbiome, BGI Research, Shenzhen 518083, China
- BGI College and Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou 450052, China
| | - Yuanqiang Zou
- BGI Research, Shenzhen 518083, China
- BGI Research, Wuhan 430074, China
- Lars Bolund Institute of Regenerative Medicine Qingdao-Europe Advanced Institute for LifeSciences, BGI Research, Qingdao 266555, China
- Shenzhen Engineering Laboratory of Detection and Intervention of Human Intestinal Microbiome, BGI Research, Shenzhen 518083, China
- BGI College and Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou 450052, China
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Liu X, Wu Z, Hu T, Lin X, Liang H, Li W, Jin X, Xiao L, Fang X, Zou Y. Comparative genomic analysis reveals niche adaption of Lactobacillus acidophilus. J Appl Microbiol 2023; 134:lxad287. [PMID: 38040628 DOI: 10.1093/jambio/lxad287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 11/01/2023] [Accepted: 11/30/2023] [Indexed: 12/03/2023]
Abstract
AIMS Lactobacillus acidophilus has been extensively applied in plentiful probiotic products. Although several studies have been performed to investigate the beneficial characteristics and genome function of L. acidophilus, comparative genomic analysis remains scarce. In this study, we collected 74 L. acidophilus genomes from our gut bacterial genome collection and the public database and conducted a comprehensive comparative genomic analysis. METHODS AND RESULTS This study revealed the potential correlation of the genomic diversity and niche adaptation of L. acidophilus from different perspectives. The pan-genome of L. acidophilus was found to be open, with metabolism, information storage, and processing genes mainly distributed in the core genome. Phage- and peptidase-associated genes were found in the genome of the specificity of animal-derived strains, which were related to the adaptation of the animal gut. SNP analysis showed the differences of the utilization of vitamin B12 in cellular of L. acidophilus strains from animal gut and others. CONCLUSIONS This work provides new insights for the genomic diversity analysis of L. acidophilus and uncovers the ecological adaptation of the specific strains.
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Affiliation(s)
- Xudong Liu
- BGI Research, Shenzhen 518083, China
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China
| | - Zhinan Wu
- BGI Research, Shenzhen 518083, China
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, China
| | | | - Xiaoqian Lin
- BGI Research, Shenzhen 518083, China
- School of Bioscience and Biotechnology, South China University of Technology, Guangzhou 510006, China
| | | | - Wenxi Li
- BGI Research, Shenzhen 518083, China
- School of Bioscience and Biotechnology, South China University of Technology, Guangzhou 510006, China
| | - Xin Jin
- BGI Research, Shenzhen 518083, China
| | - Liang Xiao
- BGI Research, Shenzhen 518083, China
- Lars Bolund Institute of Regenerative Medicine Qingdao-Europe Advanced Institute for LifeSciences, Qingdao 266555, China
- Shenzhen Engineering Laboratory of Detection and Intervention of human intestinal microbiome, Shenzhen 518083, China
- BGI College and Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou 450052, PR China
| | | | - Yuanqiang Zou
- BGI Research, Shenzhen 518083, China
- Lars Bolund Institute of Regenerative Medicine Qingdao-Europe Advanced Institute for LifeSciences, Qingdao 266555, China
- Shenzhen Engineering Laboratory of Detection and Intervention of human intestinal microbiome, Shenzhen 518083, China
- BGI College and Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou 450052, PR China
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Wang Y, Wang X, Cao XY, Zhu HL, Miao L. Comparative effectiveness of different probiotics supplements for triple helicobacter pylori eradication: a network meta-analysis. Front Cell Infect Microbiol 2023; 13:1120789. [PMID: 37256113 PMCID: PMC10226649 DOI: 10.3389/fcimb.2023.1120789] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 04/24/2023] [Indexed: 06/01/2023] Open
Abstract
Background Probiotics has been reported as an effective supplement for Helicobacter pylori eradication. However, knowledge of their comparative efficacy is still lacking. Aim In this study, we used network meta-analysis of current probiotics supplement used in standard triple therapy to assess and rank their comparative effectiveness. Methods All randomized controlled trials from three main databases (PubMed, Embase and Cochrane Library) up to April 2022 were collected and filtered to meet our criterion. We used Bayesian network meta-analysis to evaluate the eligible randomized controlled trials and gave a rank for the efficiency and incidence of side effects of each probiotics supplement. The ranking probability for each therapy was assessed by means of surfaces under cumulative ranking values. Subgroup analysis was conducted to evaluate other possible influencing factors. Results 34 eligible randomized controlled trials entered the following meta-analysis, including 9,004 patients randomized to 10 kinds of therapies. Result showed that most probiotics added therapies had better outcomes than triple therapy, among which Bifidobacterium-Lactobacillus and Bifidobacterium-Lactobacillus-Saccharomyces adjuvant therapy could obtain comprehensive benefit with high eradication rate (78.3% and 88.2% respectively), and cause few side effects. Combination of different probiotics, adding probiotics before or after triple therapy and longer duration of probiotics can improve therapeutic effect in H.pylori infected individuals. Conclusion For triple therapy of H.pylori infection, adding probiotics can increase eradication rate and bring protective effect. Considering the overall influence, Bifidobacterium-Lactobacillus or Bifidobacterium-Lactobacillus-Saccharomyces therapy can be a better choice in improving H.pylori eradication process.
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Affiliation(s)
- Yue Wang
- Medical Centre for Digestive Diseases, the Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xue Wang
- Medical Centre for Digestive Diseases, the Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xue-Yan Cao
- Medical Centre for Digestive Diseases, the Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Han-Long Zhu
- Department of Gastroenterology and Hepatology, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Lin Miao
- Medical Centre for Digestive Diseases, the Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Zhang M, Zhang C, Zhao J, Zhang H, Zhai Q, Chen W. Meta-analysis of the efficacy of probiotic-supplemented therapy on the eradication of H. pylori and incidence of therapy-associated side effects. Microb Pathog 2020; 147:104403. [PMID: 32707316 DOI: 10.1016/j.micpath.2020.104403] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 02/07/2023]
Abstract
Traditional therapies for Helicobacter pylori (H. pylori) infection remain hindered by the antibiotic resistance of the pathogen and the poor therapeutic compliance of patients. To address these issues, probiotics have been added as an adjunctive therapy. This meta-analysis aimed to evaluate the efficacy of probiotic supplementation during standard therapy on the eradication rate of H. pylori infection and incidence of therapy-related side effects. Four online databases were searched for eligible studies without language restriction. Review Manager (REVMAN, Version 5.3) was used to perform all data analyses. Forty articles including 5792 patients met our criteria and were included in the analysis. Notably, probiotic supplementation improved the eradication rate by approximately 10% relative to the control group [odds ratio (OR), 1.94, 95% confidence interval (CI): 1.70-2.22, P < 0.00001]. The incidence of total side effects (OR, 0.56, 95% CI: 0.45-0.70, P < 0.00001) and individual symptoms (e.g., diarrhea, vomiting and nausea, constipation, epigastric pain, taste disturbance) also decreased significantly with probiotic supplementation. No other differences in side effects were observed between the experimental and control groups. Moreover, a longer duration (≥10 days) of probiotic treatment had positive effects on both eradication rate of H. pylori and incidence of overall side effects.
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Affiliation(s)
- Meiyi Zhang
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, 214122, PR China; School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, 214122, PR China
| | - Chengcheng Zhang
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, 214122, PR China; School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, 214122, PR China
| | - Jianxin Zhao
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, 214122, PR China; School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, 214122, PR China
| | - Hao Zhang
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, 214122, PR China; School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, 214122, PR China; National Engineering Research Center for Functional Food, Jiangnan University, Wuxi, Jiangsu, 214122, PR China; Wuxi Translational Medicine Research Center and Jiangsu Translational Medicine Research Institute Wuxi Branch, PR China; (Yangzhou) Institute of Food Biotechnology, Jiangnan University, Yangzhou, 225004, China
| | - Qixiao Zhai
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, 214122, PR China; School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, 214122, PR China; International Joint Research Laboratory for Probiotics at Jiangnan University, Wuxi, Jiangsu, 214122, China.
| | - Wei Chen
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, 214122, PR China; School of Food Science and Technology, Jiangnan University, Wuxi, Jiangsu, 214122, PR China; National Engineering Research Center for Functional Food, Jiangnan University, Wuxi, Jiangsu, 214122, PR China; Beijing Innovation Center of Food Nutrition and Human Health, Beijing Technology and Business University (BTBU), Beijing, 100048, PR China
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Yu M, Zhang R, Ni P, Chen S, Duan G. Efficacy of Lactobacillus-supplemented triple therapy for H. pylori eradication: A meta-analysis of randomized controlled trials. PLoS One 2019; 14:e0223309. [PMID: 31577828 PMCID: PMC6774518 DOI: 10.1371/journal.pone.0223309] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 09/18/2019] [Indexed: 12/19/2022] Open
Abstract
Aim To assess the effect of Lactobacillus supplementation on Helicobacter pylori eradication rates and side effects of the triple therapy. Methods PubMed, Embase, Web of Science and Cochrane Library were searched for articles published up to July, 2019. Review Manager 5.3 and Stata 12.0 were used for statistical analyses. Results The initial database search resulted in 852 articles. Through exclusion and screening, 11 randomized controlled trials involving a total of 724 patients were finally included in this meta-analysis. The H. pylori elimination rate in the Lactobacillus supplement group was significantly higher than that in the control group (RR 1.16, 95% CI 1.08–1.25, P<0.0001). Subgroup analysis showed that the eradication rates were significantly enhanced in both adults and children group, and no significant difference was detected between Asia and Europe group. In addition, sub-analysis based on duration of Lactobacillus supplementation showed the pooled RRs in the long-term and short-term groups were 1.17 (95%CI 1.06–1.30) and 1.16 (95% CI 1.04–1.30), respectively. Regarding the Lactobacillus strains, the pooled RR was 1.33 (95% CI 1.10–1.62) in the L. casei group, 1.18 (95% CI 1.03–1.34) in the L. reuteri group while 1.02 (95% CI 0.87–1.21) in the Lactobacillus GG group. As for the total side effects, Lactobacillus supplementation significantly reduced the incidence of taste disturbance (RR = 0.36, 95% CI 0.17–0.74, P = 0.005). Conclusions Lactobacillus supplementation during the treatment of Helicobacter pylori infection can effectively improve the eradication rates, and reduce the incidence of therapy-related taste disturbance.
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Affiliation(s)
- Mingyang Yu
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Rongguang Zhang
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Peng Ni
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Shuaiyin Chen
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Guangcai Duan
- Department of Epidemiology, College of Public Health, Zhengzhou University, Zhengzhou, China
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Shi X, Zhang J, Mo L, Shi J, Qin M, Huang X. Efficacy and safety of probiotics in eradicating Helicobacter pylori: A network meta-analysis. Medicine (Baltimore) 2019; 98:e15180. [PMID: 30985706 PMCID: PMC6485819 DOI: 10.1097/md.0000000000015180] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Due to decreasing eradication rate and increasing side effects, probiotics have gradually become an important supplement to standard eradication regimens for Helicobacter pylori. OBJECTIVE To evaluate the effectiveness and safety of probiotics in facilitating the eradication of H pylori and to explore the best timing and duration of probiotic supplementation, use of eradication regimens, strains, locations, and common side effects. METHODS Eligible studies were retrieved from the PubMed, EMBASE, Cochrane Library, Web of Science, and CNKI databases, and we applied the Stata 12.0 software for the standard meta-analysis and network meta-analysis. RESULTS Forty eligible studies with 8924 patients were included in the analysis. We used a random-effects model (I = 52.1% and I = 81.4%) to analyze the eradication rate and the incidence of total side effects by intention to treat (ITT). Compared with the control group, a higher eradication rate (relative risk [RR] 1.140, 95% confidence interval (CI) 1.101-1.180, P < .001) and lower incidence of total side effects (RR 0.470, 95% CI 0.391-0.565, P < .001) were observed in the probiotic group. In the subgroup analysis, we evaluated the surface under the cumulative ranking curve scores for the before + same (75.2%), >2 weeks (92.6%), probiotic + quadruple regimen (99.9%), Lactobacillus (73.6%), multiple strains (72.1%), China (98.5%) groups. The rankings of common side effects are shown in Table 6. SUCRA scores for diarrhea (39.7%), abdominal pain (43.9%), nausea (78.8%), taste disturbance (99.6%), vomiting (7.1%), and constipation (30.9%) were reported. The consistency of all comparison groups was good. CONCLUSIONS Probiotics improved the eradication rate and reduced side effects when added to the treatments designed to eradicate H pylori. The use of probiotics before the eradication treatment and throughout the eradication treatment, and also the use of probiotics for more than 2 weeks, exerted better eradication effects. Probiotics combined with the bismuth quadruple regimen was the best combination. Lactobacillus and multiple strains were better choices of probiotic strains. The eradication effect observed in China was better than the effect observed in other countries.
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Affiliation(s)
- Xiaoguang Shi
- Department of Geriatrics and Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning
| | - Junhong Zhang
- Department of Geriatrics and Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning
| | - Lingshan Mo
- Department of Gastroenterology, The Eighth Affiliated Hospital of Guangxi Medical University, Guigang
| | - Jialing Shi
- Department of Geriatrics and Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning
| | - Mengbin Qin
- Department of Gastroenterology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region
| | - Xue Huang
- Geriatrics and Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Zhu XY, Liu F. Probiotics as an adjuvant treatment in Helicobacter pylori eradication therapy. J Dig Dis 2017; 18:195-202. [PMID: 28294543 DOI: 10.1111/1751-2980.12466] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/03/2017] [Accepted: 03/06/2017] [Indexed: 12/11/2022]
Abstract
Over 80% of individuals infected with Helicobacter pylori (H. pylori) are asymptomatic. Increased resistance to antibiotics and decreased compliance to the therapeutic regimens have led to the failure of eradication therapy. Probiotics, with direct and indirect inhibitory effects on H. pylori in both animal models and clinical trials, have recently been used as a supplementary treatment in H. pylori eradication therapy. Probiotics have been considered useful because of the improvements in H. pylori eradication rates and therapy-related side effects although treatment outcomes using probiotics are controversial due to the heterogeneity of species, strains, doses and therapeutic duration of probiotics. Thus, despite the positive role of probiotics, several factors need to be further considered during their applications. Moreover, adverse events of probiotic use need to be noted. Further investigations into the safety of adjuvant probiotics to H. pylori eradication therapy are required.
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Affiliation(s)
- Xin Yan Zhu
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fei Liu
- Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
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Talebi Bezmin Abadi A. Helicobacter pylori treatment: New perspectives using current experience. J Glob Antimicrob Resist 2017; 8:123-130. [DOI: 10.1016/j.jgar.2016.11.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/10/2016] [Accepted: 11/20/2016] [Indexed: 02/08/2023] Open
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Lau CSM, Ward A, Chamberlain RS. Probiotics improve the efficacy of standard triple therapy in the eradication of Helicobacter pylori: a meta-analysis. Infect Drug Resist 2016; 9:275-289. [PMID: 27994474 PMCID: PMC5153259 DOI: 10.2147/idr.s117886] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction Helicobacter pylori colonization is present in half of the world’s population and can lead to numerous gastrointestinal diseases if left untreated, including peptic ulcer disease and gastric cancer. Although concurrent triple therapy remains the recommended treatment regimen for H. pylori eradication, its success rate and efficacy have been declining. Recent studies have shown that the addition of probiotics can significantly increase eradication rates by up to 50%. This meta-analysis examines the impact of probiotic supplementation on the efficacy of standard triple therapy in eradicating H. pylori. Methods A comprehensive literature search was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (time of inception to 2016) to identify all published randomized control trials (RCTs) assessing the use of probiotics in addition to triple therapy for the treatment of H. pylori. Searches were conducted using the keywords “probiotics”, “triple therapy”, and “Helicobacter pylori”. RCTs comparing the use of probiotics and standard triple therapy with standard triple therapy alone for any duration in patients of any age diagnosed with H. pylori infection were included. H. pylori eradication rates (detected using urea breath test or stool antigen) were analyzed as-per-protocol (APP) and intention-to-treat (ITT). Results A total of 30 RCTs involving 4,302 patients APP and 4,515 patients ITT were analyzed. The addition of probiotics significantly increased eradication rates by 12.2% (relative risk [RR] =1.122; 95% confidence interval [CI], 1.091–1.153; P<0.001) APP and 14.1% (RR =1.141; 95% CI, 1.106–1.175; P<0.001) ITT. Probiotics were beneficial among children and adults, as well as Asians and non-Asians. No significant difference was observed in efficacy between the various types of probiotics. The risk of diarrhea, nausea, vomiting, and epigastric pain was also reduced. Conclusion The addition of probiotics is associated with improved H. pylori eradication rates in both children and adults, as well as Asians and non-Asians. Lactobacillus, Bifidobacterium, Saccharomyces, and mixtures of probiotics appear beneficial in H. pylori eradication. Furthermore, the reduction in antibiotic-associated side effects such as nausea, vomiting, diarrhea, and epigastric pain improves medication tolerance and patient compliance. Given the consequences associated with chronic H. pylori infection, the addition of probiotics to the concurrent triple therapy regimen should be considered in all patients with H. pylori infection. However, further studies are required to identify the optimal probiotic species and dose.
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Affiliation(s)
- Christine S M Lau
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; Saint George's University School of Medicine, Grenada, West Indies
| | - Amanda Ward
- Saint George's University School of Medicine, Grenada, West Indies
| | - Ronald S Chamberlain
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; Saint George's University School of Medicine, Grenada, West Indies; Department of Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ, USA; Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ, USA
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Lee CY, Shih HC, Yu MC, Lee MY, Chang YL, Lai YY, Lee YC, Kuan YH, Lin CC. Evaluation of the potential inhibitory activity of a combination of L. acidophilus, L. rhamnosus and L. sporogenes on Helicobacter pylori: A randomized double-blind placebo-controlled clinical trial. Chin J Integr Med 2016; 23:176-182. [DOI: 10.1007/s11655-016-2531-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Indexed: 01/06/2023]
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Probiotic supplementation does not improve eradication rate of Helicobacter pylori infection compared to placebo based on standard therapy: a meta-analysis. Sci Rep 2016; 6:23522. [PMID: 26997149 PMCID: PMC4800733 DOI: 10.1038/srep23522] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 03/04/2016] [Indexed: 12/13/2022] Open
Abstract
This meta-analysis included eligible randomized controlled trials (RCTs) with the aim of determining whether probiotic supplementation can improve H. pylori eradication rates. PUBMED, EBSCO, Web of Science, and Ovid databases were searched. We included RCTs that investigated the effect of combining probiotics, with or without a placebo, with standard therapy. A total of 21 RCTs that reported standard therapy plus probiotics were included. Compared to the placebo group, the probiotics group was 1.21(OR 1.21, 95% CI: 0.86, 1.69) and 1.28 (OR 1.28, 95% CI: 0.88, 1.86) times more likely to achieve eradication of H. pylori infection in intent-to-treat (ITT) analysis and per protocol (PP) analysis, respectively. Probiotics with triple therapy plus a 14-day course of treatment did not improve the eradication of H. pylori infection (OR 1.44, 95% CI: 0.87, 2.39) compared to the placebo. Moreover, the placebo plus standard therapy did not improve eradication rates compared to standard therapy alone (P = 0.816). However, probiotics did improve the adverse effects of diarrhea and nausea. These pooled data suggest that the use of probiotics plus standard therapy does not improve the eradication rate of H. pylori infection compared to the placebo.
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Molina-Infante J, Shiotani A. Practical Aspects in Choosing a Helicobacter pylori Therapy. Gastroenterol Clin North Am 2015; 44:519-35. [PMID: 26314666 DOI: 10.1016/j.gtc.2015.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Cure rates greater than 90%-95% should be expected with an antimicrobial therapy for Helicobacter pylori infection. Standard triple therapy does not guarantee these efficacy rates in most settings worldwide anymore. The choice of eradication regimen should be dictated by factors that can predict the outcome: (1) H. pylori susceptibility; (2) patients' history of prior antibiotic therapy; and (3) local data, either resistance patterns or clinical success. Currently, the preferred first-line choices are 14-day bismuth quadruple and 14-day non-bismuth quadruple concomitant therapy. Bismuth quadruple (if not used previously), fluoroquinolone-, furazolidone- and rifabutin-containing regimens might be effective rescue treatments.
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Affiliation(s)
- Javier Molina-Infante
- Department of Gastroenterology, Hospital San Pedro de Alcantara, C/Pablo Naranjo s/n, Caceres 10003, Spain.
| | - Akiko Shiotani
- Department of Internal Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama Prefecture 701-0114, Japan
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Fahey JW, Stephenson KK, Wallace AJ. Dietary amelioration of Helicobacter infection. Nutr Res 2015; 35:461-73. [PMID: 25799054 PMCID: PMC4465045 DOI: 10.1016/j.nutres.2015.03.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 03/01/2015] [Accepted: 03/02/2015] [Indexed: 12/18/2022]
Abstract
We review herein the basis for using dietary components to treat and/or prevent Helicobacter pylori infection, with emphasis on (a) work reported in the last decade, (b) dietary components for which there is mechanism-based plausibility, and (c) components for which clinical results on H pylori amelioration are available. There is evidence that a diet-based treatment may reduce the levels and/or the virulence of H pylori colonization without completely eradicating the organism in treated individuals. This concept was endorsed a decade ago by the participants in a small international consensus conference held in Honolulu, Hawaii, USA, and interest in such a diet-based approach has increased dramatically since then. This approach is attractive in terms of cost, treatment, tolerability, and cultural acceptability. This review, therefore, highlights specific foods, food components, and food products, grouped as follows: bee products (eg, honey and propolis); probiotics; dairy products; vegetables; fruits; oils; essential oils; and herbs, spices, and other plants. A discussion of the small number of clinical studies that are available is supplemented by supportive in vitro and animal studies. This very large body of in vitro and preclinical evidence must now be followed up with rationally designed, unambiguous human trials.
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Affiliation(s)
- Jed W Fahey
- Lewis B. and Dorothy Cullman Chemoprotection Center, Department of Pharmacology & Molecular Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Human Nutrition, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Katherine K Stephenson
- Lewis B. and Dorothy Cullman Chemoprotection Center, Department of Pharmacology & Molecular Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Alison J Wallace
- New Zealand Institute for Plant and Food Research Limited, Lincoln, New Zealand
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LV ZHIFA, WANG BEN, ZHOU XIAOJIANG, WANG FUCAI, XIE YONG, ZHENG HUILIE, LV NONGHUA. Efficacy and safety of probiotics as adjuvant agents for Helicobacter pylori infection: A meta-analysis. Exp Ther Med 2015; 9:707-716. [PMID: 25667617 PMCID: PMC4316960 DOI: 10.3892/etm.2015.2174] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 12/05/2014] [Indexed: 12/14/2022] Open
Abstract
The aim of the present study was to determine whether probiotics could help to improve the eradication rates and reduce the side effects associated with anti-Helicobacter pylori treatment, and to investigate the optimal time and duration of probiotic administration during the treatment, thus providing clinical practice guidelines for eradication success worldwide. By searching Pubmed, Embase, the Cochrane Central Register of Controlled Trials and the Science Citation Index, all the randomized controlled trials (RCTs) comparing probiotics as adjuvant agents of anti-H. pylori standard triple-therapy regimens with placebo or no treatment were selected. Statistical analysis was performed with the Comprehensive Meta Analysis Software. Subgroup, meta-regression and sensitivity analyses were also carried out. Twenty-one RCTs involving a total of 3,814 participants met the inclusion criteria. The pooled eradication rates of the probiotic group were 80.3% (1,709/2,128) by intention-to-treat (ITT) and 83.8% (1,709/2,039) by pro-protocol analyses; the pooled relative risk (RR) by ITT for probiotic supplementation versus treatment without probiotics was 1.12 [95% confidence interval (CI), 1.06-1.19]. A reduced risk of overall H. pylori therapy-related adverse effects was also found with probiotic supplementation (RR, 0.60; 95% CI, 0.40-0.91). The subgroup analyses showed that probiotic supplementation prior and subsequent to the treatment regimen both improved eradication rates for H. pylori infection. Furthermore, probiotic treatment lasting >2 weeks and including Lactobacillus or multiple probiotic strains significantly enhanced the efficacy. In conclusion, supplementation with probiotics for H. pylori eradication may be effective in increasing eradication rates and decreasing therapy-related side effects. Probiotic administration prior or subsequent to therapy and for a duration of >2 weeks may increase the eradication efficacy.
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Affiliation(s)
- ZHIFA LV
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P.R. China
| | - BEN WANG
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P.R. China
| | - XIAOJIANG ZHOU
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P.R. China
| | - FUCAI WANG
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P.R. China
| | - YONG XIE
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P.R. China
- Correspondence to: Dr Yong Xie, Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi 330000, P.R. China, E-mail: . Dr Huile Zheng, School of Public Health, Nanchang University, 461 Bayi Street, Nanchang, Jiangxi 330006, P.R. China, E-mail:
| | - HUILIE ZHENG
- School of Public Health, Nanchang University, Nanchang, Jiangxi, P.R. China
- Correspondence to: Dr Yong Xie, Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, 17 Yongwaizheng Street, Nanchang, Jiangxi 330000, P.R. China, E-mail: . Dr Huile Zheng, School of Public Health, Nanchang University, 461 Bayi Street, Nanchang, Jiangxi 330006, P.R. China, E-mail:
| | - NONGHUA LV
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, P.R. China
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Zhu R, Chen K, Zheng YY, Zhang HW, Wang JS, Xia YJ, Dai WQ, Wang F, Shen M, Cheng P, Zhang Y, Wang CF, Yang J, Li JJ, Lu J, Zhou YQ, Guo CY. Meta-analysis of the efficacy of probiotics in Helicobacter pylori eradication therapy. World J Gastroenterol 2014; 20:18013-18021. [PMID: 25548501 PMCID: PMC4273153 DOI: 10.3748/wjg.v20.i47.18013] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 06/28/2014] [Accepted: 07/11/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the role of probiotics in the standard triple Helicobacter pylori therapy.
METHODS: In this meta-analysis, we investigated the efficacy of probiotics in a standard triple H. pylori therapy in adults. Searches were mainly conducted in MEDLINE/PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials. Fourteen studies met our criteria, and the quality of these studies was assessed using the Jadad scale. We used STATA version 12.0 to extract data and to calculate the odds ratios (ORs), which are presented with the corresponding 95% confidence intervals (CIs). The data are presented as forest plots.
RESULTS: The pooled ORs for the eradication rates calculated by intention-to-treat analysis and per-protocol analysis in the probiotic group vs the control group were 1.67 (95%CI: 1.38-2.02) and 1.68 (95%CI: 1.35-2.08), respectively, using the fixed-effects model. The sensitivity of the Asian studies was greater than that of the Caucasian studies (Asian: OR = 1.78, 95%CI: 1.40-2.26; Caucasian: OR = 1.48, 95%CI: 1.06-2.05). The pooled OR for the incidence of total adverse effects was significantly lower in the probiotic group (OR = 0.49, 95%CI: 0.26-0.94), using the random effects model, with significant heterogeneity (I2 = 85.7%). The incidence of diarrhea was significantly reduced in the probiotic group (OR = 0.21, 95%CI: 0.06-0.74), whereas the incidence of taste disorders, metallic taste, vomiting, nausea, and epigastric pain did not differ significantly between the probiotic group and the control group.
CONCLUSION: Supplementary probiotic preparations during standard triple H. pylori therapy may improve the eradication rate, particularly in Asian patients, and the incidence of total adverse effects.
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Dang Y, Reinhardt JD, Zhou X, Zhang G. The effect of probiotics supplementation on Helicobacter pylori eradication rates and side effects during eradication therapy: a meta-analysis. PLoS One 2014; 9:e111030. [PMID: 25365320 PMCID: PMC4217763 DOI: 10.1371/journal.pone.0111030] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 09/28/2014] [Indexed: 12/22/2022] Open
Abstract
Background Previous meta-analyses reported that probiotics improve the effectiveness of Helicobacter pylori (H. pylori) eradication during antibiotic therapy, while results regarding a possible reduction of side effects remained inconclusive. Moreover, the effectiveness of different strains of probiotics has not been studied so far. It is further conceivable that probiotics will produce additional effects only if antibiotics are relatively ineffective. Methods This meta-analysis includes eligible randomized controlled trials examining effects of probiotics supplementation on eradication rates (ER) and side effects, published up to May 2014. Sub-group analysis was performed to compare different probiotic strains and antibiotic therapies with different effectiveness in controls (ER <80% vs.>80%). Publication bias was assessed with funnel plots and Harbord's test. The quality of the trials was assessed with the Cochrane risk of bias tool. Results Thirty-three RCTs involving a total of 4459 patients met the inclusion criteria in case of eradication rates of which 20 assessed total side effects in addition. Overall, the pooled eradication rate in probiotics supplementation groups was significantly higher than in controls (ITT analysis: RR 1.122, 95% CI 1.086–1.159, PP analysis: RR 1.114, 95% CI 1.070–1.159). Sub group-analysis could, however, confirm this finding only for four individual strains (Lactobacillus acidophilus, Lactobacillus casei DN-114001, Lactobacillus gasseri, and Bifidobacterium infantis 2036) and for relatively ineffective antibiotic therapies. There was a significant difference between groups in the overall incidence of side effects (RR 0.735, 95% CI 0.598–0.902). This result was, however, only confirmed for non-blinded trials. Conclusions The pooled data suggest that supplementation with specific strains of probiotics compared with eradication therapy may be considered an option for increasing eradication rates, particularly when antibiotic therapies are relatively ineffective. The impact on side effects remains unclear and more high quality trials on specific probiotic strains and side effects are thus needed.
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Affiliation(s)
- Yini Dang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China, and First Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Jan D. Reinhardt
- Institute for Disaster Management and Reconstruction, Sichuan University, Chengdu, China, and Hong Kong Polytechnical University, Hung Hom, Hong Kong, China
- Department of Health Sciences, University of Lucerne, Lucerne, Switzerland
- Swiss Paraplegic Research, Nottwil, Switzerland
| | - Xiaoying Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China, and First Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Guoxin Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China, and First Clinical Medical College of Nanjing Medical University, Nanjing, China
- * E-mail:
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Molina-Infante J, Gisbert JP. Optimizing clarithromycin-containing therapy for Helicobacter pylori in the era of antibiotic resistance. World J Gastroenterol 2014; 20:10338-10347. [PMID: 25132750 PMCID: PMC4130841 DOI: 10.3748/wjg.v20.i30.10338] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 04/09/2014] [Indexed: 02/06/2023] Open
Abstract
The efficacy of triple therapy for Helicobacter pylori infection has dramatically declined over the last decade, largely related to increasing clarithromycin resistance rates. From a microbiological standpoint, bismuth quadruple therapy is the ideal replacement since it combines drugs for which resistance does not impair its efficacy. Nonetheless, several obstacles such as availability, complexity or tolerance prevent a general implementation of bismuth quadruple therapy, so non-bismuth quadruple regimens remain the best first-line treatment in clinical practice in many geographical areas. We review the rationale and efficacy of several optimization tools (increasing the length of duration, high-dose acid suppression, probiotics), which have been largely evaluated over the last 5 years to increase the effectiveness of standard triple therapy. Then, we update available evidence on the effectiveness of several non-bismuth quadruple therapies (sequential, concomitant, hybrid, miscellaneous therapy), which have gained interest lately. We also revise evidence on the efficacy of the aforementioned optimization tools for non-bismuth quadruples schemes and, finally we provide a novel regionalized therapeutic algorithm, based on novel formulas recently developed for predicting the outcome of non-bismuth quadruple regimens, upon local antibiotic resistance rates.
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18
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Pereira MI, Medeiros JA. Role of Helicobacter pylori in gastric mucosa-associated lymphoid tissue lymphomas. World J Gastroenterol 2014; 20:684-698. [PMID: 24574742 PMCID: PMC3921478 DOI: 10.3748/wjg.v20.i3.684] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 11/19/2013] [Accepted: 12/06/2013] [Indexed: 02/06/2023] Open
Abstract
Mucosa-associated lymphoid tissue (MALT) lymphoma is an indolent extranodal marginal zone B-cell lymphoma, originating in acquired MALT that is induced in mucosal barriers as part of a normal adaptive immune response to a chronic immunoinflammatory stimulus, most notably chronic infection by Helicobacter pylori (H. pylori). This antigenic stimulation initially leads to lymphoid hyperplasia; the acquisition of additional genetic aberrations culminates in the activation of intracellular survival pathways, with disease progression due to proliferation and resistance to apoptosis, and the emergence of a malignant clone. There are descriptions of MALT lymphomas affecting practically every organ and system, with a marked geographic variability partially attributable to the epidemiology of the underlying risk factors; nevertheless, the digestive system (and predominantly the stomach) is the most frequently involved location, reflecting the gastrointestinal tract’s unique characteristics of contact with foreign antigens, high mucosal permeability, large extension and intrinsic lymphoid system. While early-stage gastric MALT lymphoma can frequently regress after the therapeutic reversal of the chronic immune stimulus through antibiotic eradication of H. pylori infection, the presence of immortalizing genetic abnormalities, of advanced disease or of eradication-refractoriness requires a more aggressive approach which is, presently, not consensual. The fact that MALT lymphomas are rare neoplasms, with a worldwide incidence of 1-1.5 cases per 105 population, per year, limits the ease of accrual of representative series of patients for robust clinical trials that could sustain informed evidence-based therapeutic decisions to optimize the quality of patient care.
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MESH Headings
- Gastric Mucosa/immunology
- Gastric Mucosa/microbiology
- Helicobacter Infections/epidemiology
- Helicobacter Infections/immunology
- Helicobacter Infections/microbiology
- Helicobacter Infections/therapy
- Helicobacter pylori/immunology
- Helicobacter pylori/pathogenicity
- Humans
- Immunity, Mucosal
- Lymphoma, B-Cell, Marginal Zone/epidemiology
- Lymphoma, B-Cell, Marginal Zone/genetics
- Lymphoma, B-Cell, Marginal Zone/immunology
- Lymphoma, B-Cell, Marginal Zone/microbiology
- Lymphoma, B-Cell, Marginal Zone/therapy
- Prognosis
- Risk Factors
- Stomach Neoplasms/epidemiology
- Stomach Neoplasms/genetics
- Stomach Neoplasms/immunology
- Stomach Neoplasms/microbiology
- Stomach Neoplasms/therapy
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19
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Oral immunization with recombinant Lactobacillus acidophilus expressing the adhesin Hp0410 of Helicobacter pylori induces mucosal and systemic immune responses. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2013; 21:126-32. [PMID: 24285819 DOI: 10.1128/cvi.00434-13] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Helicobacter pylori infection is relatively common worldwide and is closely related to gastric mucosa-associated lymphoid tissue (MALT) lymphoma, chronic gastritis, and stomach ulcers. Therefore, a safe and effective method for preventing H. pylori infection is urgently needed. Given that developing an effective vaccine against H. pylori is one of the best alternatives, H. pylori adhesin Hp0410 was expressed in the food-grade bacterium Lactobacillus acidophilus. The recombinant live bacterial vaccine was then used to orally vaccinate mice, and the immunoprotective effects of Hp0410-producing strains were investigated. H. pylori colonization in the stomach of mice immunized with the recombinant L. acidophilus was significantly reduced, in comparison with that in control groups. Furthermore, mucosal secretory IgA antibodies were elicited in the mucosal tissue of mice immunized with the recombinant bacteria, and specific anti-Hp0410 IgG responses were also detected in mouse serum. There was a significant increase in the level of protection against gastric Helicobacter infection following a challenge with H. pylori Sydney strain 1 (SS1). Our results collectively indicate that adhesin Hp0410 is a promising candidate vaccine antigen, and recombinant L. acidophilus expressing Hp0410 is likely to constitute an effective, low-cost, live bacterial vaccine against H. pylori.
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Mehling H, Busjahn A. Non-viable Lactobacillus reuteri DSMZ 17648 (Pylopass™) as a new approach to Helicobacter pylori control in humans. Nutrients 2013; 5:3062-73. [PMID: 23917169 PMCID: PMC3775242 DOI: 10.3390/nu5083062] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 06/21/2013] [Accepted: 07/22/2013] [Indexed: 12/31/2022] Open
Abstract
Prevalence of infections by Helicobacter pylori, a pathogen involved in a number of gastrointestinal diseases, remains high in developing countries. Management of infections by eradication is not always an option. Lactobacillus reuteri (L. reuteri) DSMZ17648 (Pylopass™/Lonza) specifically co-aggregates H. pylori in vitro and was shown to reduce ¹³C urea breath test in vivo. In this pilot study, we tried to replicate previous findings in an independent sample and to evaluate effects of spray-drying vs. freeze-drying of cultures. A single-blinded, placebo-controlled study was done in 22 H. pylori positive, asymptomatic adults. H. pylori levels were determined by ¹³C-urea-breath method after 14 days of supplementation, as well as after 6, 12, and 24 weeks follow-up. In the test group, but not in the placebo group, a significant reduction of H. pylori was observed. For the first time, spray-dried cells of L. reuteri DSMZ17648 have been used in a human study and results are in line with the first study results, supplementing with freeze-dried material. This is of special interest as spray-drying results in dead cell material, meaning that the effect of L. reuteri must be independent of its probiotic activity. These results confirm the potential of Pylopass™ as a novel way to reduce the load of H. pylori.
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Affiliation(s)
- Heidrun Mehling
- Experimental and Clinical Research Center, Charité Campus Berlin-Buch (CCB), Lindenberger Weg 80, Berlin 13125, Germany; E-Mail:
| | - Andreas Busjahn
- HealthTwiSt GmbH, Lindenberger Weg 80, Berlin 13125, Germany
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Helicobacter pylori VacA suppresses Lactobacillus acidophilus-induced interferon beta signaling in macrophages via alterations in the endocytic pathway. mBio 2013; 4:e00609-12. [PMID: 23760466 PMCID: PMC3685213 DOI: 10.1128/mbio.00609-12] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Helicobacter pylori causes chronic gastritis and avoids elimination by the immune system of the infected host. The commensal bacterium Lactobacillus acidophilus has been suggested to exert beneficial effects as a supplement during H. pylori eradication therapy. In the present study, we applied whole-genome microarray analysis to compare the immune responses induced in murine bone marrow-derived macrophages (BMDMs) stimulated with L. acidophilus, H. pylori, or both bacteria in combination. While L. acidophilus induced a Th1-polarizing response characterized by high expression of interferon beta (IFN-β) and interleukin 12 (IL-12), H. pylori strongly induced the innate cytokines IL-1β and IL-1α. In BMDMs prestimulated with L. acidophilus, H. pylori blocked the expression of L. acidophilus-induced IFN-β and IL-12 and suppressed the expression of key regulators of the Rho, Rac, and Cdc42 GTPases. The inhibition of L. acidophilus-induced IFN-β was independent of H. pylori viability and the virulence factor CagPAI; however, a vacuolating cytotoxin (vacA) mutant was unable to block IFN-β. Confocal microscopy demonstrated that the addition of H. pylori to L. acidophilus-stimulated BMDMs redirects intracellular processing, leading to an accumulation of L. acidophilus in the endosomal and lysosomal compartments. Thus, our findings indicate that H. pylori inhibits the development of a strong Th1-polarizing response in BMDMs stimulated with L. acidophilus by blocking the production of IFN-β in a VacA-dependent manner. We suggest that this abrogation is caused by a redirection of the endocytotic pathway in the processing of L. acidophilus. Approximately half of the world’s population is infected with Helicobacter pylori. The factors that allow this pathogen to persist in the stomach and cause chronic infections have not yet been fully elucidated. In particular, how H. pylori avoids killing by macrophages, one of the main types of immune cell underlying the epithelium, remains elusive. Here we have shown that the H. pylori virulence factor VacA plays a key role by blocking the activation of innate cytokines induced by the probiotic Lactobacillus acidophilus in macrophages and suppresses the expression of key regulators required for the organization and dynamics of the intracellular cytoskeleton. Our results identify potential targets for the treatment of H. pylori infection and vaccination, since specific inhibition of the toxin VacA possibly allows the activation of an efficient immune response and thereby eradication of H. pylori in the host.
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Gisbert JP, Calvet X, Bermejo F, Boixeda D, Bory F, Bujanda L, Castro-Fernández M, Dominguez-Muñoz E, Elizalde JI, Forné M, Gené E, Gomollón F, Lanas Á, Martín de Argila C, McNicholl AG, Mearin F, Molina-Infante J, Montoro M, Pajares JM, Pérez-Aisa A, Pérez-Trallero E, Sánchez-Delgado J. [III Spanish Consensus Conference on Helicobacter pylori infection]. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:340-74. [PMID: 23601856 DOI: 10.1016/j.gastrohep.2013.01.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 01/31/2013] [Indexed: 01/06/2023]
Affiliation(s)
- Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
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Navarro-Rodriguez T, Silva FM, Barbuti RC, Mattar R, Moraes-Filho JP, de Oliveira MN, Bogsan CS, Chinzon D, Eisig JN. Association of a probiotic to a Helicobacter pylori eradication regimen does not increase efficacy or decreases the adverse effects of the treatment: a prospective, randomized, double-blind, placebo-controlled study. BMC Gastroenterol 2013; 13:56. [PMID: 23530767 PMCID: PMC3614530 DOI: 10.1186/1471-230x-13-56] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 03/19/2013] [Indexed: 12/12/2022] Open
Abstract
Background The treatment for the eradication of Helicobacter pylori (H. pylori) is complex; full effectiveness is rarely achieved and it has many adverse effects. In developing countries, increased resistance to antibiotics and its cost make eradication more difficult. Probiotics can reduce adverse effects and improve the infection treatment efficacy. If the first-line therapy fails a second-line treatment using tetracycline, furazolidone and proton-pump inhibitors has been effective and low cost in Brazil; however it implies in a lot of adverse effects. The aim of this study was to minimize the adverse effects and increase the eradication rate applying the association of a probiotic compound to second-line therapy regimen. Methods Patients with peptic ulcer or functional dyspepsia infected by H. pylori were randomized to treatment with the furazolidone, tetracycline and lansoprazole regimen, twice a day for 7 days. In a double-blind study, patients received placebo or a probiotic compound (Lactobacillus acidophilus, Lactobacillus rhamnosus, Bifidobacterium bifidum and Streptococcus faecium) in capsules, twice a day for 30 days. A symptom questionnaire was administered in day zero, after completion of antibiotic therapy, after the probiotic use and eight weeks after the end of the treatment. Upper digestive endoscopy, histological assessment, rapid urease test and breath test were performed before and eight weeks after eradication treatment. Results One hundred and seven patients were enrolled: 21 men with active probiotic and 19 with placebo plus 34 women with active probiotic and 33 with placebo comprising a total of 55 patients with active probiotic and 52 with placebo. Fifty-one patients had peptic ulcer and 56 were diagnosed as functional dyspepsia. The per-protocol eradication rate with active probiotic was 89.8% and with placebo, 85.1% (p = 0.49); per intention to treat, 81.8% and 79.6%, respectively (p = 0.53). The rate of adverse effects at 7 days with the active probiotic was 59.3% and 71.2% with placebo (p = 0.20). At 30 days, it was 44.9% and 60.4%, respectively (p = 0.08). Conclusions The use of this probiotic compound compared to placebo in the proposed regimen in Brazilian patients with peptic ulcer or functional dyspepsia showed no significant difference in efficacy or adverse effects. Trial registration Current Controlled Trials ISRCTN04714018
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Affiliation(s)
- Tomás Navarro-Rodriguez
- Serviço de Gastroenterologia Clínica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av, Dr, Enéas de Carvalho Aguiar, 255-Cerqueira Cezar, São Paulo, SP, Brazil.
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24
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Navarro-Rodriguez T, Silva FM, Barbuti RC, Mattar R, Moraes-Filho JP, de Oliveira MN, Bogsan CS, Chinzon D, Eisig JN. Association of a probiotic to a Helicobacter pylori eradication regimen does not increase efficacy or decreases the adverse effects of the treatment: a prospective, randomized, double-blind, placebo-controlled study. BMC Gastroenterol 2013; 13:5. [PMID: 23311418 PMCID: PMC3558380 DOI: 10.1186/1471-230x-13-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 12/28/2012] [Indexed: 12/17/2022] Open
Abstract
Internet websites are a resource for patients seeking information about probiotics. We examined a sample of 71 websites presenting probiotic information. We found that descriptions of benefits far outnumbered descriptions of risks and commercial websites presented significantly fewer risks than noncommercial websites. The bias towards the presentation of therapeutic benefits in online content suggests that patients are likely interested in using probiotics and may have unrealistic expectations for therapeutic benefit. Gastroenterologists may find it useful to initiate conversations about probiotics within the context of a comprehensive health management plan and should seek to establish realistic therapeutic expectations with their patients.
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Affiliation(s)
- Tomás Navarro-Rodriguez
- Serviço de Gastroenterologia Clínica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av, Dr, Enéas de Carvalho Aguiar, 255-Cerqueira Cezar, São Paulo, SP, Brazil.
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25
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Dharmani P, De Simone C, Chadee K. The probiotic mixture VSL#3 accelerates gastric ulcer healing by stimulating vascular endothelial growth factor. PLoS One 2013; 8:e58671. [PMID: 23484048 PMCID: PMC3590171 DOI: 10.1371/journal.pone.0058671] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 02/07/2013] [Indexed: 12/12/2022] Open
Abstract
Studies assessing the effect and mechanism of probiotics on diseases of the upper gastrointestinal tract (GI) including gastric ulcers are limited despite extensive work and promising results of this therapeutic option for other GI diseases. In this study, we investigated the mechanisms by which the probiotic mixture VSL#3 (a mixture of eight probiotic bacteria including Lactobacilli, Bifidobacteria and Streptococcus species) heals acetic acid induced gastric ulcer in rats. VSL#3 was administered orally at low (6×109 bacteria) or high (1.2×1010 bacteria) dosages from day 3 after ulcer induction for 14 consecutive days. VSL#3 treatments significantly enhanced gastric ulcer healing in a dose-dependent manner. To assess the mechanism(s) whereby VSL#3 exerted its protective effects, we quantified the gene expression of several pro-inflammatory cytokines, protein and expression of stomach mucin-Muc5ac, regulatory cytokine-IL-10, COX-2 and various growth factors. Of all the components examined, only expression and protein production of VEGF was increased 332-fold on day 7 in the ulcerated tissues of animals treated with VSL#3. Predictably, animals treated with VEGF neutralizing antibody significantly delayed gastric ulcer healing in VSL#3 treated animals. This is the first report to demonstrate high efficacy of the probiotic mixture VSL#3 in enhancing gastric ulcer healing. Probiotic efficacy was effective at higher concentrations of VSL#3 by specifically increasing the expression and production of angiogenesis promoting growth factors, primarily VEGF.
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Affiliation(s)
- Poonam Dharmani
- Department of Microbiology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Claudio De Simone
- Department of Experimental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Kris Chadee
- Department of Microbiology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
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Du YQ, Su T, Fan JG, Lu YX, Zheng P, Li XH, Guo CY, Xu P, Gong YF, Li ZS. Adjuvant probiotics improve the eradication effect of triple therapy for Helicobacter pylori infection. World J Gastroenterol 2012; 18:6302-6307. [PMID: 23180952 PMCID: PMC3501780 DOI: 10.3748/wjg.v18.i43.6302] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether the addition of probiotics can improve the eradication effect of triple therapy for Helicobacter pylori (H. pylori) infection.
METHODS: This open randomized trial recruited 234 H. pylori positive gastritis patients from seven local centers. The patients were randomized to one-week standard triple therapy (omeprazole 20 mg bid, clarithromycin 500 mg bid, and amoxicillin 1000 mg bid; OCA group, n = 79); two weeks of pre-treatment with probiotics, containing 3 × 107Lactobacillus acidophilus per day, prior to one week of triple therapy (POCA group, n = 78); or one week of triple therapy followed by two weeks of the same probiotics (OCAP group, n = 77). Successful eradication was defined as a negative C13 or C14 urease breath test four weeks after triple therapy. Patients were asked to report associated symptoms at baseline and during follow-up, and side effects related to therapy were recorded. Data were analyzed by both intention-to-treat (ITT) and per-protocol (PP) methods.
RESULTS: PP analysis involved 228 patients, 78 in the OCA, 76 in the POCA and 74 in the OCAP group. Successful eradication was observed in 171 patients; by PP analysis, the eradication rates were significantly higher (P = 0.007 each) in the POCA (62/76; 81.6%, 95% CI 72.8%-90.4%) and OCAP (61/74; 82.4%, 95% CI 73.6%-91.2%) groups than in the OCA group (48/78; 61.5%, 95% CI 50.6%-72.4%). ITT analysis also showed that eradication rates were significantly higher in the POCA (62/78; 79.5%, 95% CI 70.4%-88.6%) and OCAP (61/77; 79.2%, 95% CI 70%-88.4%) groups than in the OCA group (48/79; 60.8%, 95% CI 49.9%-71.7%), (P = 0.014 and P = 0.015). The symptom relieving rates in the POCA, OCAP and OCA groups were 85.5%, 89.2% and 87.2%, respectively. Only one of the 228 patients experienced an adverse reaction.
CONCLUSION: Administration of probiotics before or after standard triple therapy may improve H. pylori eradication rates.
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Tolone S, Pellino V, Vitaliti G, Lanzafame A, Tolone C. Evaluation of Helicobacter Pylori eradication in pediatric patients by triple therapy plus lactoferrin and probiotics compared to triple therapy alone. Ital J Pediatr 2012; 38:63. [PMID: 23114016 PMCID: PMC3502296 DOI: 10.1186/1824-7288-38-63] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Accepted: 10/17/2012] [Indexed: 12/12/2022] Open
Abstract
Background To evaluate whether the addition of a probiotic could improve Helicobacter pylori (H.P.) eradication rates and reduce the side effects of treatment in children. Methods Between July 2008 and July 2011 all patients with a clinical, laboratory and endoscopic diagnosis of H.P. positive gastritis referred to our Unit were included in the study. Patients suffering from allergy to any of drugs used in the study, with previous attempts to eradicate H.P. and those who received antibiotics, PPIs or probiotics within 4 weeks were excluded from the present study. Patients were randomized into two therapy regimens (group A and B): both groups received standard triple treatment (omeprazole, amoxicillin and clarithromycin) while only group B patients were also given a probiotic (Probinul - Cadigroup). Patients compliance was evaluated at the end of the treatment. Successful eradication was defined as a negative 13 C-urea breath test (C13-ubt) result four weeks after therapy discontinuation. Results A total of 68 histopathologically proven H.P.-infection children (32 male and 36 females) were included in the study. All of the patients in both groups used more than 90% of the therapies and no patients were lost at follow up. All side effects were selflimiting and disappeared once the therapy was terminated. Epigastric pain was observed in 6 (17.6%) group A vs 2 (5.8%) group B patients (P<0.05), nausea in 3 (8.8%) group A vs 1 (2.9%) group B patients (P<0.05); vomiting and diarrhea were observed in 2(5.8%) and 8 (23.5%) group A patients, respectively and never in group B (P<0.05). There was no significant difference between the two groups in terms of constipation (5.8% in group A and B). Four weeks after the completion of therapy, 56/68 patients (82.3%) tested negative for H.P. on C13-ubt. H.P. was eradicated in 26 patients (76.4%) in group A and in 30 patients (88.2%) in group B. There was no significantly difference in the rate of H.P. eradication between group A and group B (p=0.1), although the success rate for H.P. eradication was higher in group B than in group A. Conclusion The addition of a probiotic formula to triple therapy significantly decreased the frequency of epigastric pain, nausea, vomiting and diarrhea.
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Affiliation(s)
- Salvatore Tolone
- Department of Pediatrics, Second University of Naples, Naples, Italy.
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Urgesi R, Cianci R, Riccioni ME. Update on triple therapy for eradication of Helicobacter pylori: current status of the art. Clin Exp Gastroenterol 2012; 5:151-7. [PMID: 23028235 PMCID: PMC3449761 DOI: 10.2147/ceg.s25416] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Indexed: 12/19/2022] Open
Abstract
With the rising prevalence of antimicrobial resistance, the treatment success of standard triple therapy has recently declined to unacceptable levels (ie, 80% or less). Following the failure of conventional triple therapy, novel eradication regimens have been developed including sequential therapy, concomitant quadruple therapy, hybrid (dual-concomitant) therapy, bismuth-containing quadruple therapy, and a therapy with administration of N-acetylcysteine before a culture-guided antibiotic regimen. This article reviews the literature published on Helicobacter pylori eradication in the last year, focusing on the development of alternative strategies for first-, second-, and third-line rescue therapy for the eradication of H. pylori.
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Manfredi M, Bizzarri B, Sacchero RI, Maccari S, Calabrese L, Fabbian F, De'Angelis GL. Helicobacter pylori infection in clinical practice: probiotics and a combination of probiotics + lactoferrin improve compliance, but not eradication, in sequential therapy. Helicobacter 2012; 17:254-63. [PMID: 22759324 DOI: 10.1111/j.1523-5378.2012.00944.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Sequential therapy (ST) seems to offer higher success rates than triple therapy (TT) in the eradication of Helicobacter pylori (H. pylori) infection. However, from the standpoint of therapeutic compliance, there is no difference between the two treatments. Adjuvant treatment (especially with probiotics (PB) and lactoferrin (LF)) has often improved compliance and eradication rates in patients subjected to TT, while ST had never been used in association with adjuvants. METHODS Over a period of 2 years, we randomized and divided 227 consecutive adult patients with H. pylori infection into three groups. The patients were given ST with the addition of adjuvants, as follows: group A (ST + placebo), group B (ST + LF + PB), and group C (ST + PB). Our goal was to assess therapeutic compliance, so we prepared a questionnaire to help determine the severity of the side effects. We also determined the eradication rates for the groups. RESULTS Patients with ST + placebo had the worst compliance as compared with the other two groups in terms of the absence of symptoms (p < .001 between B and A; p = .001 between C and A) and the presence of intolerable symptoms (p = .016 between B and A; p = .046 between C and A). The differences between the values for the treated groups and those for the placebo group were statistically significant. On the other hand, there was no statistically significant difference in compliance between groups B and C. The eradication rate was similar for the three groups. CONCLUSIONS Probiotics associated with ST provide optimum therapeutic compliance compared with the placebo and, despite the need to take a larger number of tablets, they should be taken into consideration as an adjuvant to therapy for H. pylori infection. The addition of LF to the PB did not bring about any further improvements in compliance. As compared with the placebo, the eradication rate of ST did not improve by adding LF + PB or by using PB alone.
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Affiliation(s)
- Marco Manfredi
- Department of Medicine, Sant'Anna Hospital Castelnovo ne' Monti, AUSL of Reggio Emilia, Reggio Emilia, Italy.
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Choi JY, Shim KN, Kong KA, Kwon KJ, Song EM, Kim SE, Jung HK, Jung SA. Meta-analysis: the Effect ofLactobacillusSupplementation onHelicobacter pyloriEradication Rates and Side Effects during Treatment. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2012. [DOI: 10.7704/kjhugr.2012.12.2.88] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Ju Young Choi
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Ki-Nam Shim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kyoung Ae Kong
- Clinical Trial Center, Ewha Womans University Medical Center, Seoul, Korea
| | - Kyoung-Joo Kwon
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Eun-Mi Song
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seong-Eun Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hye-Kyung Jung
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Sung-Ae Jung
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
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Abstract
This article reviews the literature published pertaining to Helicobacter pylori eradication over the last year. The general perception among clinicians and academics engaged in research on H. pylori has been that eradication rates for first-line therapies are falling, although some data published this year have cast doubt on this. The studies published this year have therefore focussed on developing alternative strategies for the first-line eradication of H. pylori. In this regard, clear evidence now exists that both levofloxacin and bismuth are viable options for first-line therapy. The sequential and "concomitant" regimes have also been studied in new settings and may have a role in future algorithms also. In addition, data have emerged that the probiotic Saccharomyces boulardii may be a useful adjunct to antibiotic therapy. Other studies promote individualized therapies based on host polymorphisms, age, and other such demographic factors.
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Affiliation(s)
- Anthony O'Connor
- Department of Gastroenterology, Adelaide and Meath Hospital incorporating the National Children's Hospital/Trinity College Dublin, Dublin, Ireland.
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