Optimizing the Routine Use of Clinical Guidelines by Addition of Supplements (Probiotics and/or Bismuth) to Helicobacter pylori Eradication Protocols in a Clarithromycin Resistant and Tetracycline/Bismuth Naive Area: A Real-World Data Retrospective Analys of 402 Cases (2016-24) in a Single Gastroenterology Unit

Background: The society guidelines for Helicobacter pylori (H. pylori) eradication, due to the increasing incidence of clarithromycin resistance in the last decade turned to rec-ommend the use tetracycline-bismuth-based protocols as first line treatment. The availability of tetracycline and bismuth containing medicines raising an issue in many countries, limiting the routine use of these protocols. Literature search showed une-quivocal information about the additional value of probiotics to eradication protocols. Direct comparison data of the effect of available bismuth compounds and different probiotic strains on eradication outcome are limited. Goal: The aim of our investigation was to find the optimal eradication protocols, sup-plementations and treatment duration for routine clinical use in our gastroenterology unit in a highly clarithromycin resistant and tetracycline-bismuth-naïve area. Materials and methods: We conducted a retrospective real-world data analysis of 402 cases between 2016-24. H. pylori infection was proved by histological examination of samples obtained from the antrum by gastroscopy, for the evaluation of treatment success or failure, 14C breath tests and stool H. pylori antigen tests were performed. Results: Despite regional clarithromycin resistance pattern, supplementation of the basic clarithromycin-based protocol with bismuth and probiotic in a treatment dura-tion of 14 days, lead to high and comparable success rates to the recommended first line tetracycline-based regimens. When tetracycline-based combination is available, it is recommended to use it with additional probiotic to achieve the best possible out-come. Comparison of the effect of available bismuth preparations on treatment success showed no significant difference. Generally, probiotic containing protocols are more successful, comparing to those treatments that not containing this supplement. No sta-tistical difference was found between the positive effect on success rates of those four probiotic strain, where sample size allowed statistical analysis. A promising result of two case series supplemented with a distinct probiotic combination (Lactobacillus reu-teri ATCC PTA 6475, Lactobacillus reuteri Protectis® DSM 17938) were found with 85.2% and 100.0% success rates.