Efficacy of Probiotics Regimens for Helicobacter Pylori Eradication: A Systematic Review, Pairwise, and Network Meta-Analysis of Randomized Controlled Trials

Background: Helicobacter pylori (H. pylori) infection increases the risks of chronic gastritis, peptic ulcer diseases, and the incidence of gastric cancer. However, antibiotic resistance and adverse effects led to the emergence of alternative treatments such as probiotics supplementation. This systematic review and network meta-analysis aims to assess the efficacy and safety of incorporating probiotics into the various eradication regimens for H. pylori.

Methods: We searched PubMed, Embase, Scopus, Cochrane, and Web of Science from inception to May 2023, for randomized controlled trials (RCTs) comparing standard therapy (triple or quadrable therapy). for H. pylori with or without probiotic supplementation. Dichotomous data was reported using an odds ratio (OR) for intention to treat and risk ratios (RR) for side effects with a 95% confidence interval (CI).

Results: We included 91 RCTs involving 13,680 patients. Adding probiotics to standard treatment was associated with a higher H. pylori eradication rate in the intention-to-treat (ITT0 analysis (78.75% vs 62.43%, OR= 1.62, 95% CI: 1.41 to 1.87, P < 0.0001), and per-protocol (PP) analysis (80.33% vs 72.63%, OR= 1.60, 95% CI: 1.34 to 1.91, P < 0.0001). Meanwhile, dyspepsia, gastric ulcer, and peptic ulcer were comparable in both groups. The probiotics group was associated with significantly fewer side effects including, abdominal pain (RR= 0.68, 95% CI: 0.54 to 0.86), bad taste (RR=0.64, 95% CI: 0.53 to 0.78), diarrhea (RR= 0.49, 95% CI: 0.40 to 0.61), epigastric pain/bloating (RR =0.76, 95% CI: 0.65 to 0.88), headache/dizziness (RR=0.46, 95% CI: 0.29 to 0.74), (RR=0.65, 95% CI: 0.55 to 0.77), or nausea/vomiting (RR= 0.69, 95% CI: 0.56 to 0.83). The network meta-analysis showed that, compared to the placebo, Bifidobacterium longum had the highest efficacy in eradicating H. pylori (ITT: 81.06% vs 64.88%, PP: 88% vs 75.71%) (OR= 2.52, 95% CI: 1.18 to 5.49).

Conclusion: Adding probiotics to standard H. pylori therapy not only increased the rate of eradication but also reduced some of the adverse reactions throughout therapy, particularly nausea, vomiting, diarrhea, abdominal pain, epigastric pain/bloating, and taste issues.