Dr. Kumar’s Take
Eradicating H. pylori means a heavy antibiotic load, and the gut usually registers it. In this randomized, double-blind trial, adding Saccharomyces boulardii to standard triple therapy did not significantly change the eradication rate, but it did cut diarrhea and epigastric discomfort and left patients with better dyspepsia scores after treatment. For many patients, tolerability is the difference between completing therapy and dropping out, so this kind of benefit matters in practice.
Key Takeaways
- 124 adults (mean age 48 ± 14.25 years) with H. pylori infection received 14 days of triple therapy (clarithromycin 500 mg twice daily, amoxicillin 1000 mg twice daily, lansoprazole 30 mg twice daily) plus either S. boulardii or placebo.
- Eradication was higher in the S. boulardii group (71%, 44/62) than placebo (59.7%, 37/62), but the difference was not statistically significant (p > .05).
- Diarrhea: 9 patients (14.5%) on S. boulardii versus 19 (30.6%) on placebo (p < .05).
- Epigastric discomfort: 9 patients (14.5%) on S. boulardii versus 27 (43.5%) on placebo (p < .01).
- Post-treatment Glasgow Dyspepsia Questionnaire scores were better with S. boulardii: 1.38 ± 1.25 versus 2.22 ± 1.44 (p < .01).
- Diffuse abdominal pain, abdominal gas, taste disturbance, urticaria, and nausea were similar in both groups.
Actionable Tip
When prescribing 14-day triple therapy for H. pylori (clarithromycin, amoxicillin, and a PPI), adding S. boulardii may reduce diarrhea and epigastric discomfort and improve tolerability. Counsel the patient that this is about symptom burden, not about improving the odds of eradication.
Study Summary
Cindoruk and colleagues randomized 124 patients with H. pylori infection (44 male, 80 female) to 14 days of triple therapy plus S. boulardii or plus placebo, in a prospective, double-blind, placebo-controlled design. Dyspeptic symptoms were recorded with a modified Glasgow Dyspepsia Questionnaire, side effects and tolerability with a symptom-based questionnaire, and H. pylori status was rechecked 6 weeks after eradication therapy was completed.
Study Design
- Participants: 124 patients with H. pylori infection, mean age 48 ± 14.25 years
- Intervention Group: 14-day triple therapy (clarithromycin 500 mg b.i.d., amoxicillin 1000 mg b.i.d., lansoprazole 30 mg b.i.d.) + S. boulardii
- Control Group: Same 14-day triple therapy + placebo
- Measurements:
- H. pylori status rechecked 6 weeks after completion of therapy
- Dyspeptic symptoms by modified Glasgow Dyspepsia Questionnaire
- Side-effect profile and tolerability by symptom-based questionnaire
- Follow-up Duration: Through the 14 days of therapy and 6 weeks after completion
Results
- Eradication: 71% (44/62) with S. boulardii versus 59.7% (37/62) with placebo, p > .05
- Diarrhea: 14.5% (9/62) with S. boulardii versus 30.6% (19/62) with placebo, p < .05
- Epigastric discomfort: 14.5% (9/62) with S. boulardii versus 43.5% (27/62) with placebo, p < .01
- Glasgow Dyspepsia Questionnaire score after treatment: 1.38 ± 1.25 (range 0 to 5) with S. boulardii versus 2.22 ± 1.44 (range 0 to 6) with placebo, p < .01
- Diffuse abdominal pain, abdominal gas, taste disturbance, urticaria, and nausea: similar in both groups
Biological Rationale
- S. boulardii may blunt antibiotic-induced disturbance of gut flora, which is the most likely route to the lower diarrhea rate seen here.
- The authors report that the reduction in post-treatment dyspepsia symptoms was independent of H. pylori status, so the symptom benefit does not depend on clearing the organism.
- The yeast did not change the eradication rate, which fits a tolerability effect rather than any direct anti-H. pylori action.
Strengths & Limits
Strengths:
- Prospective, randomized, double-blind, placebo-controlled design.
- Both eradication and symptom outcomes were measured, with dyspepsia scored by a modified Glasgow Dyspepsia Questionnaire.
Limitations:
- With 62 patients per arm, the trial was not powered to settle a difference in eradication rate.
- The 11-point difference in eradication did not reach statistical significance.
- Follow-up ended 6 weeks after therapy, so recurrence and longer-term outcomes are untested.
- A single antibiotic regimen was tested, so results may not carry to areas with different resistance patterns.
Related Studies and Research
- Saccharomyces boulardii in the prevention of antibiotic‑associated diarrhoea: meta‑analysis
- Saccharomyces boulardii in the prevention of antibiotic‑associated diarrhoea in children: RCT
- SB + Amoxicillin‑Clavulanate Effects on Gut Microbiota (RCT)
- High‑Dose Vancomycin + SB for Recurrent C. difficile
- 🎙️ Saccharomyces boulardii Explained: Podcast Episode
FAQ
Should S. boulardii be added routinely in all H. pylori triple therapy regimens?
I think it is a reasonable addition when tolerability is the concern. In this trial it reduced diarrhea and epigastric discomfort and improved post-treatment dyspepsia scores, but it had no significant effect on eradication, so I would not add it expecting a better cure rate.
Does reducing side effects translate into better completion of eradication therapy?
This trial measured tolerability, not completion rates, so I am drawing a clinical inference: patients who feel better on a 14-day regimen are more likely to finish it, and finishing it is what drives eradication.
Bottom Line
Adding Saccharomyces boulardii to 14-day triple therapy for H. pylori reduced diarrhea and epigastric discomfort and improved post-treatment dyspepsia scores, but it did not significantly change the eradication rate. If tolerability is the problem, it is a worthwhile adjunct. If eradication is the problem, the answer lies in the antibiotic regimen, not the probiotic.
