A total of 156 patients were included in the current study; and patients positive for H. Pylori infection (n =156) were randomly assigned to 3 groups: 52 patients (Group P) received conventional quadruple therapy plus L. reuteri, 52 patients (Group S) received conventional quadruple therapy plus S. boulardii daily, for 2 weeks, and 52 patients were in the control group (Group C). At the end of the treatment period, all the subjects continued to take proton pump inhibitor (PPI) alone for 14 days, and then, no medication was given for 2 weeks again. During follow-up, gastrointestinal symptoms were assessed using an evaluation scale (Glasgow dyspepsia questionnaire (GDQ)), and adverse events were assessed at 7, 14, 21, and 28 days. The work flow for overall procedure is shown in Fig. 1.
2.1. Study Design
This double-blind, randomized placebo-controlled trial was done to evaluate the effect of adding S. boulardii or DSMZ 17648 strain of Lactobacillus reuteri to traditional quadruple therapy on eradication rates, as well as clinical and pathological aspects of H. Pylori infection which was designed according to the Consolidated Standards of Reporting Trials (CONSORT) guideline . Patients who were referred to the Gastroenterology Clinic of the Valiasr Hospital and met all the inclusion criteria were included in the study. Then, patients were randomly assigned to treatment groups using oblique coins.
2.2. Inclusion Criteria
Symptomatic H. pylori-positive patients of both sexes aged between 16 - 74 years old whose infection was confirmed by endoscopy and pathology were included in the study.
2.3. Exclusion Criteria
Patients with less than 15 years of age, pregnant or lactating women, patients with hepatic, cardio-respiratory, renal, and neoplastic diseases, those receiving antibiotics, PPIs, bismuth salts, or probiotics within the previous 4 weeks, patients with the history of gastric surgery and sensitivity to any of the drugs used in this study, those receiving any medication interfering with action of the lactobacilli, patients with the history of undergoing surgical procedures influencing stomach or small intestine with potential interference with the study, e.g., gastrectomy or gastric bypass, patients with autoimmune disease, organ transplantation, weight changes >3 kg over the last 3 months, those with the history of eradication of H. pylori infection, lactose intolerance, oral intake of antibiotics <3 months ago, alcohol or drug abuse, and those participating at other clinical trials at the same time were excluded from the study.
2.4. Ethical Considerations
This study was approved by the Research Council and Ethics Committee of the Birjand University of Medical Sciences with the ethics code of IR.BUMS.REC.1398.305. It was also registered on the website of the Iranian registry of clinical trials (IRCT) with the following number: IRCT20200106046021N1 on 14/01/2020. An informed written consent was obtained from all the patients. No costs were imposed on patients. The drugs used in the study, as well as the dose administered to patients, had no side effects or toxicity. The final report and analysis were performed without names of the participants in the study. The modified Glasgow dyspepsia questionnaire (GDQ) was used to record dyspeptic symptoms before starting therapy and at the end of the follow-up period.
2.5. Treatment Protocol
The interventions were based on the standard quadruple therapy regimen containing bismuth for H. Pylori, which included 1 g of Amoxicillin twice daily, 500 mg of Clarithromycin twice daily, 40 mg of PPI twice daily, and 120 mg of bismuth subcitrate (two tablets, twice daily). Patients in Group S were given 1 capsule of DAILYEAST® (saccharomyces boulardii supplement 250 mg, Zist Takhmir, Tehran, Iran) b.i.d in combination with anti H. pylori quadruple therapy. Patients in Group P were given 2 capsules of PHYLOSHOT® (100 mg of non-viable Lactobacillus reuteri DSMZ 17648, Lactobacillus acidophilus, Lactobacillus casei, and Bifidobacterium lactis>109 CFU, Zist Takhmir, Tehran, Iran) b.i.d in combination with anti H. pylori quadruple therapy. Patients in the control group were also given a placebo capsule b.i.d along with anti H. pylori quadruple therapy. Duration of treatment was equal to 14 days.
At the end of the treatment period, all the subjects continued to take PPI alone for 14 days. Then, the patients were given no medication for 2 weeks before having their first fecal antigen test at the end of the second week. Then, after another 4 weeks, they had a second stool antigen test.
2.6. Evaluation of Treatments҆ Side Effects and Tolerability
Using a previously reported questionnaire, the side effect profile and tolerability were assessed during the follow-up period. Subjects were carefully instructed and trained on filling out questionnaires in order to achieve the highest level of compliance in registering any potential treatment-related side effects. Subjects were asked to report any side effect during and thereafter therapy, such as bitter taste, nausea, vomiting, epigastric discomfort, abdominal pain, and diarrhea.
2.7. Statistical Analysis
After entering the SPSS 24 software, the data were described using central and dispersion indices for quantitative variables and frequency and agreement tables for qualitative variables. Homogeneity of groups was assessed using analysis of variance (ANOVA) and Chi-Square tests. Marginal logistic model with generalized estimating equation (GEE) approach was used for modeling the changes in complications during the study. In the tests, significance level was set at 0.05.