Efficacy of probiotics pretreatment in <i>Helicobacter pylori</i> eradication therapy: a systematic review and meta-analysis of clinical outcomes

Probiotics inhibit <i>Helicobacter pylori (H. pylori)</i> growth and alter gut microbiome, in addition to alleviating the side effects of <i>H. pylori</i> eradication. It has also been reported that <i>H. pylori</i> be eradicated after fecal microbiota transplantation in some cases. However, whether probiotics used before <i>H. pylori</i> eradication improves the eradication rate remains unclear. This study evaluates their role through a systematic review and meta-analysis. We searched PubMed, EMBASE, the Cochrane Library, and the Conference Proceedings Citation Index up to January 31, 2024, to identify randomized controlled studies (RCTs) assessing the efficacy of probiotics used before <i>H. pylori</i> eradication. Meta-analyses of eradication rates were performed. Twelve eligible RCTs with 2,144 participants were included. The intention-to-treat analysis revealed that the overall eradication rate of <i>H. pylori</i> was higher in the probiotics pretreatment group compared to the control group (80.34% vs. 70.49%), with a risk ratio (RR) of 1.14 (95% CI: 1.08 to 1.19; <i>I²</i> = 36%) and side effects were less (16.0% vs. 28.3%, RR = 0.59, 95% CI 0.41 to 0.84). The per-protocol analysis yielded similar results (86.43% vs. 76.88%, RR = 1.12, 95% CI: 1.08 to 1.17; <i>I²</i> = 57%). Subgroup analyses, considering factors like geographic location, eradication regimens, and probiotic combinations, consistently confirmed the benefits. Finally, probiotics pretreatment durations of 14 days or more, as well as the study designs <i>pre vs. free</i> and <i>pre and combine vs. free</i>, demonstrated significant effects. Shorter durations and other study designs with fewer studies did not show significant effects. There is moderate to high evidence to suggest that probiotics pretreatment improves <i>H. pylori</i> eradication rate and reduces side effects. These findings highlight the potential value of gut microbiome modulation in <i>H. pylori</i> treatment and offer a new direction for addressing the challenges of antibiotic resistance and treatment failure.