The effects of probiotics on the treatment of Helicobacter pylori eradication in children. Reply from the Author.

I read the study by Akcam et al,1 and I have 2 comments on this interesting study. First, Akcam et al1 addressed that they found no evidence in terms of the eradication rate (ER) of Helicobacter pylori (H. pylori), or impact on adverse effects obtained after the addition of probiotics to the standard triple treatment (STT). Their observation could be confidently added to the conflicting results on that issue reported in the literature. The authors did well in partly attributing the different strains and doses of probiotics employed in the related studies reported in the literature as a possible explanation of the conflicting results.1 However, I presume that the following 2 points might also be explanatory: 1. the resistance rate of H. pylori strains to the commonly used anti-H. pylori antibiotics used is increasingly reported worldwide as culture-based therapy is not always considered in the pediatric clinical settings; and 2. a review of the literature on that issue revealed that most of the conducted studies, including Akcam et al’s study1 employed the same methodology in terms of evaluating the regimen of concomitant probiotics with STT versus STT. Interestingly, an open label randomized observational clinical study was recently conducted on H. pylori infected cohort (age 12-80 years) to test 3 different regimens of H. pylori eradication treatment: STT with a concomitant probiotic added at the same time; starting the probiotic for 2 weeks before initiating STT along with the probiotic; and the third regimen consists of the probiotic given concomitantly to sequential treatment. The 3 regimens in the case group were compared to a control group of patients treated with the traditional STT. The study showed that the ER for the traditional STT was 68.9%, and adding the probiotic to STT led to a successful ER of 83% (p<0.001). Pre-treatment with 2 weeks of probiotic before adding it to STT increased the success ER to 90.5%.2 Similar improvement in ER was noted when the probiotic was added as an adjuvant to the sequential therapy leading to an ER of 90.8%.2 I presume that employing a similar methodology on H. pylori infected pediatric patients in a large randomized controlled trial (RCT) is advocated, and improved H. pylori ER is solicited. Second, yogurt is a traditional food worldwide. The nutritional aspects of yogurt for reducing the risk of chronic health conditions and improving nutrient status are well-emphasized. It is produced by bacterial fermentation of milk using a culture of Lactobacillus delbrueckii subsp. bulgaricus and Streptococcus thermophilus bacteria. In addition, other lactobacilli and bifidobacteria are also sometimes added during, or after yogurt culture.3 Interestingly, the probiotics‐ containing yogurt has been found to offer benefits to restore Bifidobacterium spp./Escherichia coli (E. coli) ratio in children, and suppress the H. pylori load with increment of serum IgA, but with reduction in IL‐6 in H. pylori‐infected children.4 Reviewing the literature revealed only one study5 evaluating the potential activity of the probiotic food (yogurt) as an adjuvant to STT for eradication of H. pylori infection in children. Although the study demonstrated no adjuvant effect,5 determining the efficacious effect of adding commercial yogurt to the STT of H. pylori infection in children still need to be extensively investigated. If that regimen proved to be efficacious in large clinical trials, I presume that its advantages would be manifold for H. pylori infected pediatric patients in terms of higher ER, better compliance, reduced cost, improved tolerability, and less therapy-related side effects, particularly diarrhea.