Supplementing vitamins C and E to standard triple therapy for the eradication of Helicobacter pylori

Factors associated with treatment failure, and possible applications of probiotic bacteria in the arsenal against Helicobacter pylori

INTRODUCTION

Helicobacter pylori is a widespread helical Gram-negative bacterium, which causes a variety of stomach disorders, such as peptic ulcer, chronic atrophic gastritis, and gastric cancer. This microbe frequently colonizes the mucosal layer of the human stomach and survives in the inhospitable microenvironment, by adapting to this hostile milieu.

AREAS COVERED

In this extensive review, we describe conventional antibiotic treatment regimens used against H. pylori including, empirical, tailored, and salvage therapies. Then, we present state-of-the-art information about reasons for treatment failure against H. pylori. Afterward, the latest advances in the use of probiotic bacteria against H. pylori infection are discussed. Finally, we propose a polymeric bio-platform to provide efficient delivery of probiotics for H. pylori infection.

EXPERT OPINION

For effective probiotic delivery systems, it is necessary to avoid the early release of probiotics at the acidic stomach pH, to protect them against enzymes and antimicrobials, and precisely target H. pylori bacteria which have colonized the antrum area of the stomach (basic pH).

The Effects of Vitamins and Micronutrients on Helicobacter pylori Pathogenicity, Survival, and Eradication: A Crosstalk between Micronutrients and Immune System

Helicobacter pylori as a class I carcinogen is correlated with a variety of severe gastroduodenal diseases; therefore, H. pylori eradication has become a priority to prevent gastric carcinogenesis. However, due to the emergence and spread of multidrug and single drug resistance mechanisms in H. pylori, as well as serious side effects of currently used antibiotic interventions, achieving successful H. pylori eradication has become exceedingly difficult. Recent studies expressed the intention of seeking novel strategies to improve H. pylori management and reduce the risk of H. pylori-associated intestinal and extragastrointestinal disorders. For which, vitamin supplementation has been demonstrated in many studies to have a tight interaction with H. pylori infection, either directly through the regulation of the host inflammatory pathways or indirectly by promoting the host immune response. On the other hand, H. pylori infection is reported to result in micronutrient malabsorption or deficiency. Furthermore, serum levels of particular micronutrients, especially vitamin D, are inversely correlated to the risk of H. pylori infection and eradication failure. Accordingly, vitamin supplementation might increase the efficiency of H. pylori eradication and reduce the risk of drug-related adverse effects. Therefore, this review aims at highlighting the regulatory role of micronutrients in H. pylori-induced host immune response and their potential capacity, as intrinsic antioxidants, for reducing oxidative stress and inflammation. We also discuss the uncovered mechanisms underlying the molecular and serological interactions between micronutrients and H. pylori infection to present a perspective for innovative in vitro investigations, as well as novel clinical implications.

Vitamins and Helicobacter pylori: An Updated Comprehensive Meta-Analysis and Systematic Review

Background

Over recent decades, epidemiological studies have shown relationships between vitamins and Helicobacter pylori (H. pylori) infection and eradication, but the results are controversial.

Methods

A comprehensive meta-analysis and systematic review were conducted to clarify the relationships between common types of vitamins and H. pylori. We applied meta-regression, subgroup analysis and sensitivity analysis to obtain available evidence. Articles published from January 1991 to June 2021 in PubMed, EMBASE, and the Cochrane Library were searched.

Results

In total, we identified 48 studies. The results indicate that H. pylori -positive patients had lower serum vitamin B₁₂ [standardized mean difference (SMD) = −0.30; 95% confidence interval (CI): −0.53 – −0.08], folate (SMD = −0.69; 95% CI: −1.34 – −0.04), vitamin C (SMD = −0.37; 95%CI: −0.57 – −0.18) and vitamin D (SMD = −0.34; 95% CI: −0.49 – −0.18) levels than H. pylori-negative patients. Patients in which H. pylori had been successfully eradicated had higher serum vitamin D levels (SMD = 1.37; 95% CI: 0.37–2.38) than in patients in which eradication had been unsuccessful. The serum vitamin B₁₂ levels of H. pylori-positive patients improved after successful H. pylori eradication therapy (SMD = 1.85; 95% CI: 0.81–2.90), and antioxidant vitamin supplementation to an H. pylori eradication regimen improved the eradication rate (risk ratio = 1.22; 95% CI: 1.02–1.44 for per-protocol analysis; risk ratio = 1.25; 95% CI: 1.06–1.47 for intention-to-treat analysis).

Conclusions

H. pylori infections decrease the serum levels of several types of vitamins, eradication of H. pylori could rescue its adverse effects, and antioxidant vitamin supplementation may improve the H. pylori eradication rate.

Systematic Review Registration

identifier: CRD42021268127.

Vegetable Extracts and Nutrients Useful in the Recovery from Helicobacter pylori Infection: A Systematic Review on Clinical Trials

Helicobacter pylori (H. pylori) infections affect almost half of the world’s population, with gradually increasing incidence in developed countries. Eradication of H. pylori may provide significant benefits to the affected individual by healing a number of gastrointestinal and extra-digestive disorders. But due to increased microbial resistance and lack of patient adherence to the therapy, the eradication rate of H. pylori is below 80% with current pharmacological therapies. The usage of botanicals for their therapeutic purposes and medicinal properties have been increased in last decades. They can be use as alternative H. pylori treatments, especially against drug-resistant strains. Epidemiological studies have revealed that people with lower vegetable and micronutrient intake may be at increased risk of H. pylori infection. We have undertaken a review of clinical trials to evaluate the efficacy of vegetable extracts and micronutrients in patients with H. pylori. Various databases, such as Google Scholar, PubMed, Scopus, Web of Science, and the Cochrane Library, were searched for the articles published in English. A total of 24 clinical studies (15 for vegetable extracts and 9 for micronutrients) were selected to be reviewed and summarized in this article. Vegetable extracts (Broccoli sprouts, curcumin, Burdock complex, and Nigella sativa) and micronutrients (vitamin C and E) were not found to be as effective as single agents in H. pylori eradication, rather their efficacy synergized with conventional pharmacological therapies. Conversely, GutGard was found to be significantly effective as a single agent when compared to placebo control.

Consumption of Vitamin K and Vitamin A Are Associated With Reduced Risk of Developing Emphysema: NHANES 2007-2016

Chronic obstructive pulmonary disease (COPD) comprising of emphysema and chronic bronchitis are the most common chronic respiratory diseases that impart a huge economic and clinical burden. Factors other than smoking and air pollutants can cause inflammation and emphysematous changes in the lung airspaces or alveoli have been understudied. Using a cross-sectional study design, we assessed the association of dark green vegetables, vitamin K and Vitamin A with emphysema status among adults at U.S. These nutrients have a role in lung biology. A complete case NHANES data (n = 17,681) was used. After adjusting for modifiable and non-modifiable confounders, consumption of recommended amounts of vitamin K was associated with 39% decrease in odds (Odds Ratio: 0.61; 95% CI: 0.40–0.92, P-val: 0.02) of emphysema. Similarly consumption of recommended amounts vitamin A dose was associated with 33% decrease in odds (Odds Ratio: 0.67; 95% CI: 0.44–1.00, P-val: 0.05) of emphysema. Vitamin K shows an inverse association suggesting that it may be important in slowing the emphysematous process. Vitamin A is important in maintaining the anti-inflammatory process. Together vitamin K and vitamin A are important in the lung health.

Helicobacter pylori treatment in Turkey: Current status and rational treatment options

According to the TURHEP study, the prevalence of Helicobacter pylori in Turkey is 82.5%. After FDA approval in 1995, many countries have used standard triple therapy (proton pump inhibitor 40 mg b.i.d clarithromycin 500 mg b.i.d and amoxicillin 1 gr b.i.d) for Helicobacter pylori treatment. In the beginning, eradication rates were above 90% in many countries; however, current studies have demonstrated a prominent decrease in successful treatment rates, even down to 60%. This unfavorable reduction stimulated searches for new treatment protocols. Treatment protocols differ according to country, prevalence, cost-effectiveness, antibiotic resistance, CYP2C19 polymorphism and eradication rates. Thus, each country/region needs to revise its own therapeutic results and the efficacy of various eradication regimens in the treatment of Helicobacter pylori. This report aims to review the current status of Helicobacter pylori treatment in Turkey and to provide recommendations for rational therapeutic considerations for the eradication of the bacterium.

The effect of antioxidants on Helicobacter pylori eradication: A systematic review with meta-analysis

BACKGROUND

The efficacy and safety of the addition of antioxidants to triple or quadruple therapy were unclear.

MATERIALS AND METHODS

This systematic review was performed in accordance with the PRISMA 2009 guidelines. A systematic search of PubMed, EMBASE, and the Cochrane Library databases was conducted to identify potentially relevant publications using the following keywords: ([Helicobacter pylori] or [H. pylori] or [Hp]) and ([antioxidant] or [vitamin] or [N-acetylcysteine] or [curcumin] or [cranberry]). The primary end-point of this study was to evaluate the efficacy of the addition of antioxidants to triple or quadruple therapy according to ITT and PP analysis. The second end-points were side effects and the comparative efficacy in terms of H. pylori eradication according to different antioxidant and antibiotic combinations.

RESULTS

We included 9 studies with 1260 participants. The total eradication rate of H. pylori in the group combining eradication therapy with antioxidants was not superior to that without antioxidants according to the ITT (pooled RR [95% CI] = 1.17 [0.99-1.38]; P = 0.07) and PP analysis (pooled RR [95% CI] = 1.15 [0.99-1.34; P = 0.07]. There were no differences regarding side effects between the two groups (pooled RR [95% CI], 1.36 [0.81-2.28]; P = 0.24). However, the eradication regimen with vitamin supplementation (1400 mg/day) showed a significant, superior efficacy in eradication relative to those without supplementation (pooled RR [95% CI] = 1.57 [1.35, 1.84]; P < 0.01). In particular, in the amoxicillin-clarithromycin-based subgroup, the crude H. pylori eradication rate determined by ITT analysis was 81.3% and 68.6% for eradication therapy with and without antioxidant supplementation, respectively, which was a statistically significant difference (pooled RR [95% CI] = 1.23 [1.02-1.49]; P = 0.03).

CONCLUSIONS

The addition of antioxidants (vitamin, N-acetylcysteine, curcumin, cranberry) to amoxicillin-clarithromycin-based therapy could improve the eradication rate, and vitamin supplementation might be effective at a high dosage. However, antioxidant supplements have no impact on improving side effects.

Vitamin C and Helicobacter pylori Infection: Current Knowledge and Future Prospects

The gram-negative bacterium, Helicobacter pylori (H. pylori), infection is predominantly known for its strong association with development of gastric diseases, including gastritis, peptic ulcers, and stomach cancer. Numerous clinical reports show that ascorbic acid deficiency has been connect with gastritis. Vitamin C levels both in gastric acid and serum have constantly been affirmed to be low in subjects with H. pylori infected gastritis and peptic ulcers. Ascorbic acid supplementation likely relates to reduced incidences of bleeding from peptic ulcers and gastric cancer. H. pylori eradication is shown to increase vitamin C levels, while the benefits of ascorbic acid oral intake to increase the effectiveness of H. pylori-eradication therapy are controversial. Recent studies suggest that ascorbate intake intravenously, but not orally; pharmacologic ascorbate concentrations up to 30 mmol/L in blood, several millimolar in tissues as well as in interstitial fluid, are easily and safely achieved. Pharmacologic ascorbate can exert pro-oxidant effects locally as a drug by mediating hydrogen peroxide (H₂O₂) formation, which was applied to animal and clinical trials of cancer, sepsis, and severe burns etc. In this review, we summarize current understanding of the associations of vitamin C and H. pylori infection, and outline some potential strategies for H. pylori intervention from emerging advances on ascorbic acid physiology and pharmacology.

Assessment of the use of vitamin C and E supplements concomitantly to antibiotic treatment against Helicobacter pylori: A systematic review and meta-analysis

INTRODUCTION

Helicobacter pylori infections affect almost 50% of the world population, constituting a risk factor for benign and malignant gastrointestinal diseases. The increased resistance to antibiotic treatment against this infection represents a dilemma in the search of other therapeutic alternatives.

OBJECTIVE

To determine the efficacy of the use of vitaminC and E supplements concomitantly to antibiotic treatment against H. pylori infections.

METHODS

We performed a systematic review on the MedLine (PubMed), Embase and Cochrane Central Register of Clinical Trials (CENTRAL) databases, searching for studies evaluating the efficacy of vitaminC and/or E supplements in the antibiotic treatment of H. pylori infections. The primary outcome was eradication of the infection. The secondary outcome was the adverse effects. The meta-analysis was conducted using the random effects method.

RESULTS

Ten studies were included and analyzed in two groups. The first group, which was comprised by 973patients, compared the use of supplementation with vitaminC and E, showing that, without discriminating the number of antibiotics used, there was no relationship with the eradication of the infection (OR: 1.98 [95%CI: 0.92-4.29] P=.08). The triple or quadruple antibiotic therapy had no effect on eradication rates either (OR 1.80 [95%CI: 0.64-5.08] P=.26 and OR: 2.84 [95%CI: 0.51-15.56] P=.22, respectively). No effect on the eradication rates was observed either in the group that only assessed the use of vitaminC, comprised by 702patients (OR: 1.17 [95%CI: 0.58-2.31] P=.65). Only four studies reported adverse effects, the most common one being nausea.

CONCLUSIONS

Supplementation with vitaminC and E in the antibiotic treatment against H. pylori has no effect. However, the reviewed studies had several biases and differences in the dosage of the supplements and antibiotics administered.

Oral mucositis caused by Candida glabrata biofilms: failure of the concomitant use of fluconazole and ascorbic acid

OBJECTIVES

Candida glabrata is becoming one of the most prevalent pathogenic yeasts in cases of oral diseases. Mucositis is an recurrent oral infection in immunocompromised patients, and the actual guidelines recommend the use of fluconazole (Flu) for many cases. However, the azole resistance by C. glabrata is renowned, causing a reduced therapeutic response, especially when it occurs in biofilms. In this study, we performed an in vitro evaluation of an alternative pharmacotherapy for C. glabrata biofilm infections, combining ascorbic acid (AA) with Flu. AA is recognized for degrading β-glucans, an important compound of the biofilm matrices, which prevent drug diffusion.

MATERIALS AND METHODS

Routine clinical 30 or 40 mg/l doses of Flu were applied to C. glabrata biofilms simultaneously with 200 or 300 mg/l of AA.

RESULTS

The results showed that this combination effectively promoted the degradation of the biofilm network, but unfortunately, also stimulated the growth of the yeasts population due to release of several glucose monomers during β-glucans hydrolysis.

DISCUSSION

AA lead to the hydrolysis of the β-glucans of the matrix, liberating glucose molecules which are used as carbon souce by the yeasts, thus suppressing the desired antifungal effect of the drug combination with Flu.

CONCLUSIONS

Unlike to what happens in treatment of bacterial infection, AA should not be used together with Flu in the treating oral mucositis caused by Candida.

Update on the Diagnosis and Management of Helicobacter pylori Infection in Adults

Treatment of Helicobacter pylori infection is becoming increasingly challenging due largely to the rising rates of antimicrobial resistance and to the relative complexity of treatment regimens. If a reliable test to assess the antimicrobial sensitivity/resistance of H. pylori was readily available, treatment would be more focused and-presumably-more effective. However, antimicrobial sensitivity testing is difficult to obtain in most parts of the United States. Therefore, physicians have to rely on clinical judgment in selecting treatment regimens for their infected patients. The aims of this review are to summarize recent treatment recommendations and to examine available evidence for how we might improve on our current treatment selections. Information on this review is directed primarily toward physicians practicing in the United States.

Helicobacter pylori: Management in 2013

Helicobacter pylori (H. pylori) is a prevalent, worldwide, chronic infection. Choice of treatment can be modified according to antibiotic-resistance rates of H. pylori. The ideal therapeutic regimen for H. pylori infection should achieve an eradication rate of ≥ 80%. In some countries, triple therapy with a proton-pump inhibitor (PPI), clarithromycin, and amoxicillin or metronidazole is still the best option. Bismuth-containing quadruple therapy consisting of bismuth salts, tetracycline, metronidazole and PPI, may be the preferred option in countries with clarithromycin resistance > 20%. Sequential therapy including a PPI and amoxicillin given for the first 5 d, followed by triple therapy including a PPI, clarithromycin, and nitroimidazole antimicrobial (all twice daily) for the remaining 5 d, can be another option for the first-line treatment of H. pylori. Recent data suggest that treatment with PPI, levofloxacin, and amoxicillin for 10 d is a good choice for second-line therapy. Concomitant therapy consisting of PPI, amoxicillin, clarithromycin and metronidazole is another option for second-line treatment. If second-line treatment also fails, it is recommended to culture H. pylori from biopsy specimens and perform antimicrobial susceptibility testing. Rescue treatment should be based on antimicrobial susceptibility.