Intern Emerg Med
DOI 10.1007/s11739-013-1013-z
IM - ORIGINAL
Lactobacillus reuteri in the treatment of Helicobacter pylori
infection
Maria Pina Dore • Marianna Cuccu •
Gianni Mario Pes • Alessandra Manca •
David Yates Graham
Received: 29 September 2013 / Accepted: 21 October 2013
Ó SIMI 2013
Abstract Probiotics have proven to be useful in the
treatment of a number of gastrointestinal diseases. Probi-
otics may compete directly with Helicobacter pylori, pos-
sibly by interference with adherence or by the production
of antimicrobial molecules. Lactobacillus reuteri has been
shown to inhibit H. pylori in vitro and in vivo, and theo-
retically may play a role in eradication therapy. The aim of
this study was to examine the efficacy of L. reuteri in
H. pylori eradication therapy. This was an open label single
center study. H. pylori infection was defined as positive
gastric histopathology and 13C-UBT. Intervention con-
sisted of L. reuteri (DSM 17938) 108 cfu plus pantoprazole
20 mg twice a day for 8 weeks. Eradication was defined as
a negative 13C-UBT, 4–6 weeks post therapy. Compliance
was considered good if at least 90 % of the total number of
the pills were taken. 21 of 22 subjects completed the study
without protocol violation (mean age 52 years; 36 % men).
L. reuteri plus pantoprazole twice a day cured 13.6 % (3/
22; 95 % CI 2.9–34.9 %) of patients with H. pylori
infection by ITT analysis and 14.2 % (3/21; 95 % CI
3.0–36 %) by PP analysis. Overall urease activity assessed
before and 4–6 weeks post therapy showed a significant
reduction with a difference of mean of 38.8 vs. 25.4 by
one-tailed test (P = 0.002). In conclusion, L. reuteri may
have a potential role in H. pylori eradication therapy if the
cure rate can be improved by changes in dose, dosing
interval, or duration of therapy.
M. P. Dore (&)  M. Cuccu  G. M. Pes  A. Manca
Dipartimento di Medicina Clinica e Sperimentale,
Clinica Medica, University of Sassari,
Viale San Pietro 8, 07100 Sassari, Italy
e-mail: mpdore@uniss.it
M. P. Dore  D. Y. Graham
Baylor College of Medicine, Houston, TX, USA
Keywords Probiotics  Lactobacillus reuteri 
H. pylori  Treatment
Introduction
Helicobacter pylori infection is etiologically involved in
the gastritis-associated diseases, gastric ulcer, duodenal
ulcer, gastric adenocarcinoma, and primary gastric B cell
lymphoma and may play a role in some cases of non-ulcer
dyspepsia. Cure of H. pylori infection dramatically alters
the natural history of gastritis and its sequelae. Currently,
antibiotics in combination with antisecretory therapy are
the standard of care for patients with H. pylori infections.
However, increasing antimicrobial resistance has made
successful treatment of H. pylori infections a challenge as
the effectiveness of many commonly recommended treat-
ments has declined to unacceptably low levels [1, 2].
Newer regimens have improved treatment success, how-
ever, the widespread occurrence of the infection in many
countries and the need of two or three antimicrobials
suggest that antimicrobial resistance may soon undermine
these currently more successful combinations [3].
The clinical manifestations of infectious diseases typi-
cally represent an interaction between the infecting
microbe and the host, both of which may influence the
outcome [4]. Normally, the local microbiome provides a
stable environment that resists colonization by pathogens.
To understand, and to enhance the ability to manipulate,
the normal microbiome with therapeutic intention is an
area of active research. Probiotics are live bacteria that may
confer a health benefit to the host [5]. In the early 20th
century, the Russian Nobel laureate Élie Metchnikoff [6]
suggested the possibility of colonizing the gut with bene-
ficial flora. Currently Lactobacillus and Bifidus spp. are the
123

most common microbes used as probiotics in the gastro-
intestinal tract [7, 8].
Probiotics have been used in the therapy of H. pylori
infection, and have proven useful in reducing side effects
of traditional antimicrobial therapy and for enhancing
patients’ compliance [9]. Some strains of L. reuteri have
previously been shown to prevent the early stage of
H. pylori colonization in the human gastrointestinal tract,
possibly by inhibition of H. pylori binding to putative
glycolipid receptor molecules [10]. Colonization has been
associated with alterations of the immune response of the
gastrointestinal mucosa [11]. Importantly, L. reuteri has
also been shown to produce an antimicrobial compound,
3-hydroxy propionaldehyde (reuterin), which is a broad
spectrum antibiotic against Gram negative and positive
bacteria including H. pylori [12, 13].
This was a pilot study to investigate the efficacy of
L. reuteri for the treatment of human H. pylori infection.
Methods
Patients
This study was a prospective, single center, open label pilot
study. Patients scheduled for upper endoscopy for any
reason and found to be positive for H. pylori infection were
invited to enter.
Exclusion criteria
Exclusion included: severe gastritis (mucosa intensively
hyperemic, granular and fragile, easily bleeding by the
scope touch), peptic ulcer, pregnancy or lactation; malig-
nancy, severe liver, heart, kidney or endocrine diseases or
any other clinically significant medical condition, alcohol
abuse, drug addiction, or a history of allergy to pantop-
razole or L. reuteri. Patients who received bismuth com-
pounds, antisecretory drugs, or antibiotics during the
4 weeks before endoscopy were also excluded.
Written informed consent was obtained from all par-
ticipants, and the study was approved by the local ethics
committee. There was no pharmaceutical company partic-
ipation in any phase of the study.
Definition of H. pylori infection
Two biopsy specimens were taken from the antrum, one
from the angulus, and two from the gastric corpus for
histology to assess the presence of H. pylori. H. pylori
infection was defined as the presence of typical histology
and bacteria on histologic examination of the gastric
biopsies stained by H&E and GIEMSA and a positive 13C-
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Intern Emerg Med
UBT. Post-treatment success was defined by a negative
13
C-UBT 30–40 days after completing therapy.
13
C-Urea breath test
The 13C-UBT was performed according to a standardized
protocol, the sensitivity and specificity of which have been
reported to be of 95 % [14]. All breath tests were analyzed
at the same laboratory using a single gas isotope ratio mass
spectrometer (ABCA, Europe Scientific, Crewe, UK).
Medication
The intervention consisted of L. reuteri (DSM 17938,
ReuflorÒ, BioGaia AB, Sweden) 108 cfu/tablet plus pan-
toprazole 20 mg twice a day. The cfu declared contained
per tablet was confirmed in two different labs (Sassari and
Houston). The choice of the probiotic was based on the
previous anecdotal experience. No treatment was admin-
istered thereafter. The L. reuteri was administered fasting
at least 2–3 h before the mid-day and evening meals.
Pantoprazole 20 mg was given just before breakfast and
dinner. All drugs were given for 60 days. The duration of
treatment chosen for the study was arbitrary. The cost of
the drugs used for treatment (pantoprazole plus L. reuteri
tablet) was € 141.66.
Patient compliance
The patients were evaluated by a physician for compliance
and side effects after completing treatment and at follow-
up by direct questioning. Side effects including diarrhea,
nausea, vomiting, stomach ache, taste disturbance, dizzi-
ness, headache, skin rash, constipation and lack of appetite;
were graded as mild (did not limit daily activities), mod-
erate (limited daily activities to some extent), or severe
(made daily activities all but impossible), and recorded.
Study design and statistical analysis
A two-stage design was applied. In the two-stage design
the patients are divided into two groups. At the completion
of the first stage, an interim analysis is made to determine if
the second stage should be conducted (e.g., a stopping rule
is utilized). If the number of patients responding is greater
than a certain amount, the second stage will be con-
ducted—otherwise, not. The optimal two-stage design to
test the null hypothesis that P B 0.200 versus the alterna-
tive P C 0.350 has an expected sample size of 36 and a
probability of early termination of 0.630. After testing the
therapy on 20 patients in the first stage, the trial would be
terminated if four or fewer responded and the details would
be reconsidered (e.g., dose, dosing interval etc.). If more
Intern Emerg Med

than four were cured, a total of 62 patients would be
studied. If the total number cured was less than or equal to
17, the drug would be rejected. Analysis of H. pylori
eradication efficacy was performed on an intention-to-treat
(ITT) basis including all eligible patients enrolled in the
study, and on a per-protocol (PP) basis excluding patients
lost to the follow-up and protocol violations.
therapy showed a significant reduction with a difference of
means of 38.8 vs. 25.4 by one-tailed test (P = 0.002)
(Fig. 1). Treatment failures by L. reuteri-based therapy
were, subsequently, cured with bismuth-based quadruple
therapy twice a day [15].
Patient compliance and side effects

Overall tolerability was good. Excellent compliance

Results (100 %) was achieved in all cases. Data on side effects
were available for all 21 treated patients. No patient
A total of 22 consecutive patients fulfilling the inclusion complained of side effects.
criteria were enrolled in stage 1 (19 women, median age
51 years, range 21–68 years). All subjects had experienced
dyspeptic symptoms. The enrollment stopped after the first Discussion
stage according to the study design (four or fewer patients
responded to the treatment). No patient had peptic ulcer Lactobacillus species are rod-shaped Gram positive bac-
disease, gastric or duodenal erosions. Twenty-two patients teria able to produce lactic acid leading to the micro-
took the medications as prescribed and H. pylori eradica- environment acidification [16]. Lactobacillus spp. have the
tion status was assessed after treatment. One patient was capacity to colonize the gastric mucosa [17] and the lactic
dropped from the study because he received antibiotics for
pneumonia. None were lost to the follow-up (Table 1). Table 1 Intervention status of patients enrolled in the study
Status Patients
H. pylori eradication
Received intervention 22
21 patients completed the study with one protocol viola- Drop-out 1
tion. Twelve patients were treatment naive for H. pylori Lost to follow-up 0
infection and nine patients had previous H. pylori treat- Completed trial 21
ments that failed to cure the infection. L. reuteri plus Intervention ineffective 18
pantoprazole twice a day cured 13.6 % (3/22; 95 % CI Cure rate ITT 14 % (3/22)
2.9–34.9 %) of patients with H. pylori infection by ITT 95 % CI 2.9–34.9
analysis and 14.2 % (3/21; 95 % CI 3.0–36 %) by PP Cure rate PP 14 % (3/21)
analysis (Table 1). The cured patients included one patient 95 % CI 3.0–36
with a history of several previous unsuccessfully therapies. ITT intention-to-treat analysis, PP per-protocol analysis, CI confi-
Overall urease activity assessed before and 4–6 weeks post dence interval

Fig. 1 Difference in urease 120

activity assessed before and I 13C-UBT II 13C-UBT
4–6 weeks post therapy by 13C-
urea breath test (UBT) 100
Delta 13C- UBT Value

80

60

40

20

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Patient number

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acid produced by Lactobacilli has been shown to inhibit the
growth of H. pylori at concentrations of 50–156 mmol/L
[18]. Pre-treatment of rats with L. rhamnosus GG at
109 cfu/mL twice daily for three consecutive days mark-
edly reduced the ethanol-induced mucosal lesion area by
45 %, and significantly increased the basal mucosal pros-
taglandin E(2) and PGE(2) levels suggesting that a local
gastroprotective action may also be present [19]. L. gasseri
in rat models also enhanced gastric ulcer healing of acetic
acid-induced gastric ulcer [20]. These studies show a
potential beneficial effect of Lactobacilli in the stomach.
In a study from Japan, administration of L. reuteri strain
ATCC 55730, four times daily for 8 weeks significantly
decreases 13C-UBT delta levels in H. pylori positive sub-
jects, demonstrating a suppression of H. pylori urease
activity and H. pylori density. H. pylori density was
investigated on the base of cfu obtained from the biopsy
gastric cultured mucosa. Patients were divided in a low
density (\1 9 105 cfu/mL), moderate density (between
1 9 105 and 5 9 105 cfu/mL), and high-density group
(5 9 105 cfu/mL). The individual UBTs were then corre-
lated to the established H. pylori quantity [21]. In a study
from Italy, patients were assigned to receive standard 7-day
triple without or with L. reuteri supplementation; or a
7-day triple therapy with a probiotic mixture; or a 14-day
standard triple therapy plus a probiotic mixture. Overall, H.
pylori eradication was achieved in up to 80 % of patients.
A statistically significant difference among the different
regimens (range 53–71 %) was not reported [22]. Despite
this result other studies have demonstrated that Lactobacilli
can produce beneficial effects [23–25]. The beneficial
effects described for Lactobacillus strains include being
able to stabilize the mucosal barrier by increasing mucin
expression, reducing bacterial overgrowth, stimulating
mucosal immunity and synthesizing antioxidant substances
[25]. Lactic acid producing bacteria also generate a variety
of metabolic products that are capable of interfering with
the growth of other microbes [26]. However, none of these
observations alone or together have prompted the use of
Lactobacillus species to cure H. pylori infection.
There have been a number of studies evaluating the
probiotic effects of Lactobacillus strains in reducing anti-
microbial side effect, enhancing compliance and improving
the cure rate with traditional H. pylori therapies in humans
[27–30]. Following a 3-week intake of 180 mL of LC-1
acidified milk twice a day in a placebo-controlled study a
decrease in gastric inflammation and H. pylori density is
reported. LC-1 acidified milk is fermented milk containing
107 cfu of L. johnsonii La1 per mL (Hirz, Production Plant
and Nestle Research Centre, Orbe, Switzerland). During
the last 2 weeks of therapy, volunteers in both groups were
treated with clarithromycin 500 mg twice a day. Clari-
thromycin eradicates H. pylori in 26 % of the subjects and
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Intern Emerg Med
LC-1 does not improve the antibiotic effect [27]. In an
uncontrolled study, Michetti et al. [28] report a decrease in
urease activity as assessed by UBT in 80 % of patients
positive for H. pylori infection treated for 2 weeks with
50 mL of L. johnsonii (La1) supernatant combined with
either omeprazole 20 mg four times a day or with placebo.
In accordance with these results a decrease in urease
activity of 76 % was also observed in our patients. How-
ever, our study did not assess H. pylori urease activity or H.
pylori density and our assessment was done at least
4 weeks after stopping therapy, a time lapse that should
have allowed any direct effect to have dissipated. Sub-
sequent studies are needed to assess the mechanism and
whether the effect was L. reuteri related. In addition, we
cannot exclude that such a phenomenon depends on the
60-day pantoprazole therapy itself. Because this was an
open label study, the absence of a control group with
pantoprazole without L. reuteri prevents any definite con-
clusion. An open label crossover study in 31 H. pylori
positive Japanese subjects reports a slight, but significant
decrease (Excess 13CO2 (%0); 26.6 ± 13.7 vs.
20.9 ± 11.8; P \ 0.05), in urease activity following con-
sumption of 90 g of yogurt containing L. gasseri (LG 21)
twice a day for 8 weeks [29]. Other studies have reported
beneficial effects of Lactobacillus strains when added to
the triple therapies against H. pylori and a meta-analysis by
Wang et al. [30] on the efficacy and safety of Lactobacillus
and Bifidobacterium-containing probiotic compound prep-
aration in H. pylori eradication therapy, report an overall
beneficial effects of probiotics. Eradication odds ratio
(OR), was available for 1469 patients (10 trials; 708 in the
probiotics supplementation group and 761 in the control
group). The pooled OR by ITT analysis and by PP analysis
in the probiotics supplementation over without probiotics
was 2.066 (95 % CI 1.398–3.055) and 2.321 (95 % CI
1.715–3.142) in each group except in patients accepting
rescue therapy, and in children. The incidence of total side
effects is significantly decreased in the probiotics supple-
mentation group (OR = 0.305; 95 % CI 0.117–0.793) [30].
Subgroup analysis for Lactobacillus was not performed.
In another study, 120 H. pylori positive patients were
randomized to receive rabeprazole, clarithromycin and
amoxicillin, either with or without a lyophilized and
inactivated culture of L. acidophilus twice daily. A sig-
nificantly higher eradication rate was observed in the L.
acidophilus-supplemented group (88 %), with respect to
the control group (72 %) [31]. Diarrhea, nausea and taste
disturbance, assessed by questionnaire, were significantly
reduced in the Lactobacillus strain GG-supplemented
group. Saggioro et al. [32] in a randomized, placebo-con-
trolled pilot study published as an abstract reported 30
dyspeptic patients, positive for H. pylori infection by his-
tology, rapid urease test (CLO-test) and 13C-UBT who
Intern Emerg Med
were randomly and blindly assigned on either omeprazole
20 mg plus L. reuteri 89105 cfu twice a day before
breakfast and dinner or omeprazole 20 mg plus placebo
twice a day for 30 days. Patients were examined for H.
pylori status by all the three tests 4 weeks after the end of
therapy. L. reuteri plus omeprazole eradicated H. pylori
infection in 9 of 15 treated patients (60 %) vs. no eradi-
cation occurred in the control population (omeprazole
alone) (P \ 0.0001) [31]. Differences between our study
and the Saggioro study (14 vs. 60 %) included different
geographic areas, different H. pylori strains (Venetian vs.
Sardinian), possibly differences in L. reuteri strains, doses,
timing and duration of administrations. We believe the
results are most consistent with L. reuteri having cured
some patients particularly as the cure rate with PPI alone
averages zero. Nevertheless, these results will need to be
confirmed and to be useful clinically the effectiveness will
need to be improved possibly by alterations in the duration,
amount of cfu, or frequency of administration, etc.
Acknowledgments This work was not financially supported.
Conflict of interest None.
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