The Effect of Lactobacillus Reuteri Probiotic as an Adjunct Treatment for Helicobacter Pylori Infection in Adults

The prime discovery of Helicobacter pylori (H. pylori) in chronic gastritis patients by Marshall and Warren in 1982 has geared a frenetic pace in H. pylori research. H. pylori is a helix-shaped microaerophilic gram negative bacterium colonising gastric epithelium leading to disruption of protective mucosal layer by inflammatory process and gastric acid secretion.

H. pylori remains as one of the commonest bacterial pathogens causing chronic infection in the adult population with at least 50% of the global population being infected. The prevalence is even higher in developing countries with up to 80% of them being affected. Although some of the patients with H. pylori infection are asymptomatic, 10-20% of them may progress into H. pylori associated disease such as chronic gastritis, peptic ulcer disease and gastric malignancy. The clinical heterogeneity is believed to be due to different degree of virulence across different H. pylori strains.

The American College of Gastroenterology (ACG) has outlined the standard therapies of H. pylori infection, dividing them into first line and salvage therapy. Treatment regime is chosen based on previous antibiotics exposure, antibiotics allergy and resistance.[7] The eradication rate of 90% is regarded as successful in which, Kyoto Global Consensus Report recommended the similar value as a cut-off point to guide the selection of empirical treatment in each region. Clarithromycin triple therapy (clarithromycin, amoxicillin/metronidazole and proton pump inhibitor, PPI) or referred as standard triple therapy (STT) in our study is recommended as first line therapy for patients who are macrolide-naive and/or reside in low clarithromycin-resistance area. For regions with high clarithromycin resistance rate (more than 15%), ACG guideline recommends administration of bismuth quadruple, non-bismuth quadruple or concomitant therapies.

The Maastricht V/Florence Consensus report has outlined the guidelines on diagnosis and therapeutic strategies in H. pylori infection. The report highlighted failure of many countries to hit at least 80% intention-to-treat eradication rate.[9] Amongst the contributing factors are emerging antibiotics resistance, poor compliance, adverse effects of antimicrobial regime leading to poor treatment adherence, high bacterial load and impairment of gastric mucosal immunity.

Regionally, the Bangkok Consensus Report by Vilaichone et al in 2018 has studied the prevalence of H. pylori infection in nine ASEAN countries. The study demonstrated high prevalence of H. pylori in ASEAN countries ranging between 20% to 69%. Despite Malaysia having the lowest H. pylori prevalence of 20%, the eradication rates failed to meet the minimum 80% target when given STT for 7 days. Qua et al (2010) and Leow et al (2018) reported the eradication rate of 71.2% and 79.3% respectively. Extending duration of STT from seven to fourteen days illustrated marked improvement of eradication rate to 88.6% but it was still below the successful eradication target of 90%.