Kefir Improves the Efficacy and Tolerability of Triple Therapy in Eradicating Helicobacter pylori

Introduction

T he eradication of Helicobacter pylori has become a cornerstone in the treatment of chronic gastritis and gastroduodenal ulcer disease. ^1,2 In general, H. pylori eradication therapy should be simple, effective, and well tolerated. The current recommendation is that treatment should achieve an eradication rate of at least 80% based on an intention-to-treat analysis or 90% based on a per protocol analysis. ³ Triple therapies using a proton pump inhibitor and two antibiotics are the most widely accepted treatment for H. pylori infection ^4,5 and generally meet this recommendation. Nevertheless, eradication rates obtained with present triple therapies are decreasing, probably because of increased resistance of H. pylori strains to antibiotics. ⁶

Mounting evidence has suggested that probiotics are beneficial in a range of different gastrointestinal conditions. ^7,8 Probiotics are live microorganisms that when administered in adequate amounts confer a health benefit on the host and include Streptococcus thermophilus, Enterococcus species, Saccharomyces species, and various species of lactobacilli and bifidobacteria. ⁹ Although the administration of probiotics alone does not seem to be sufficient to eradicate H. pylori, ¹⁰ some ^11,12 but not all ^{13 –16} studies have suggested that probiotics supplementation to triple therapy may increase the eradication rates. Additionally, there is evidence to suggest that probiotics may reduce the side effects of triple therapy. ^13,14

Kefir is a probiotic mixture prepared by culturing fresh or pasteurized milk with kefir grains containing lactobacilli, lactic streptococci, yeasts, and acetic acid bacteria. ¹⁷ Although several studies have suggested that kefir may be beneficial for lactose intolerance and other intestinal diseases, ^7,18 there has been no formal prospective work to look for any positive contribution that kefir might give to eradication rates and tolerability profile of triple therapy for H. pylori eradication. Here we sought to address this issue in a randomized, double-blind, single-center study of patients from Turkey.

Subjects and Methods

Results

Discussion

In the present study, we have shown that triple therapy with adjunctive kefir increases H. pylori eradication rates and has a positive impact on H. pylori triple therapy-related adverse effects in dyspeptic patients.

Because current triple therapy for H. pylori infection is frequently associated with resistance to antibiotics, ¹⁹ there has been much interest in alternative treatment methods (including probiotics) to control H. pylori infection. Although Oh et al. ²⁰ initially suggested that probiotics may produce soluble factors capable of killing H. pylori, these findings were not subsequently confirmed by Wendakoon et al. ¹⁰ However, the same research group has suggested that probiotics—although not sufficient for eradicating the infection—may be very effective in the inhibition of H. pylori growth. ¹⁰ In clinical studies, the addition of probiotics in the form of yogurt has been proved to be successful in reducing H. pylori eradication rates in some ^11,12 but not all ^{13 –16} studies. Kefir contains several major strains of bacteria not commonly found in yogurt, including Lactobacillus caucasus, Leuconostoc spp., Acetobacter spp., and Streptococcus spp. ^21,22 Although in this study we did not directly compared the effects of kefir and yogurt on H. pylori eradication rates, further research aiming to compare kefir with other fermented dairy products is warranted to address this issue.

An interesting finding of our study is that diarrhea, headache, nausea, and abdominal pain were less prevalent and milder in patients who received kefir plus triple therapy. There is evidence to suggest that probiotics may have a positive impact on H. pylori therapy-related adverse effects, ^13,14 and data from meta-analysis have shown that the frequency of diarrhea associated with triple therapy is reduced when probiotics are added. ²³ The reduction in adverse effects as observed in our study following kefir addition may have important implications for compliance of triple therapy.

Our pilot results must be considered within the context of study limitations. The number of patients in each treatment arm was relatively small. Only patients of Turkish descent were enrolled in this study. Data suggest that treatment regimens for H. pylori from industrialized countries may not necessarily be translatable to the developing world. ¹² In addition, we did not know the exact amount and distribution of probiotics in the kefir consumed. Finally, our study cannot address the important mechanistic question concerning the mechanisms of the observed effect of kefir on the tolerability of standard triple therapy. However, the clinically important, statistically significant observation made in this study may stimulate further research in the field.

In summary, this study is the first to report that the addition of kefir to triple therapy increased H. pylori eradication rates and decreased triple therapy-related adverse effects. Our findings suggest that the addition of kefir into triple therapy might be an option to increase its tolerability profile and the H. pylori eradication rate. These results firmly support the previous observation on the potential usefulness of fermented milk-based probiotic preparations for the improvement of H. pylori eradication protocols. ^{24 –26}