Helicobacter pylori (H. pylori) is a widespread pathogen that infects approximately half of the global population (1). Although improved sanitary conditions have reduced the incidence of H. pylori infection (2), it remains a significant cause of various gastrointestinal and extraintestinal disorders, particularly as a major risk factor for gastric cancer. Thus, successful eradication of H. pylori is crucial for reducing gastric cancer risk (2, 3).

Functional Dyspepsia (FD) is classified as a brain-gut interaction disorder (DGBI), characterized by upper abdominal pain or burning sensation, early satiety, and postprandial fullness. Its etiology is multifactorial, involving H. pylori infection, dietary habits, gastric physiological abnormalities, psychological factors, and duodenal inflammation (4). Animal models have shown that H. pylori infection induces gastric sensorimotor alterations similar to those observed in FD patients, which can normalize after H. pylori eradication (5). Meta-analyses have demonstrated the superior efficacy of H. pylori eradication over other therapeutic modalities in ameliorating FD symptoms (6, 7).

Currently, bismuth quadruple therapy remains the primary first-line regimen for H. pylori eradication (1). However, escalating resistance rates and non-standardized treatment approaches have reduced the success rates of initial eradication, leading to a higher prevalence of treatment failures. The definition of refractory H. pylori infection varies: the sixth edition of the Chinese Consensus defines it as persistence after two or more standard eradication treatments (8), while the American College of Gastroenterology (ACG) guidelines consider failure of the first-line treatment alone as refractory (9). Although guidelines recommend bismuth quadruple therapy as an empirical salvage regimen and advocate for antibiotic sensitivity testing in salvage therapy (8, 10, 11), repeated treatment failures raise concerns about multidrug resistance, secondary antibiotic resistance, and increased adverse drug reactions. Despite the ideal utility of antibiotic sensitivity testing, its widespread clinical application is hindered by prolonged turnaround times and high costs. Consequently, some patients continue to experience treatment failures despite the use of sensitive antibiotics. Therefore, enhancing the efficacy of salvage treatment represents a critical clinical challenge in the management of H. pylori infections.

China’s latest guidelines recommend combining bismuth quadruple therapy with traditional Chinese medicine or substituting traditional Chinese medicine for bismuth to enhance the eradication rate of H. pylori, alleviate patient symptoms, and reduce adverse reactions (8). Weisu Granules is a standardized herbal formulation primarily utilized for the treatment of functional dyspepsia and chronic gastritis (12). The primary ingredients of Weisu granules include Perilla frutescens (Zi Su Geng), Cyperus rotundus (Xiang Fu), Citrus reticulata (Chen Pi), Citri Sarcodactylis Fructus (Foshou), Aurantii Fructus (Zhi Ke), Areca catechu (Bing Lang), and Gallus gallus domesticus (Ji Nei Jin). The active constituents of Weisu Granules, particularly flavonoids like hesperidin and volatile oils, have been shown to modulate the brain-gut axis and improve gastric compliance (12). In the context of H. pylori infection, these compounds may help restore the gastric mucosal barrier and alleviate the low-grade inflammation that persists even after the pathogen is suppressed. Recent research indicates that combining Weisu granules with triple therapy effectively increases H. pylori eradication rates (93.88% vs. 73.47%) and significantly reduces gastrointestinal symptom scores and the incidence of adverse reactions (13).

Berberine, another Chinese herbal medicine, is an isoquinoline alkaloid derived from Coptis chinensis and other Berberis plants (14). Studies have shown that berberine derivatives can penetrate the mucus layer and effectively eradicate H. pylori biofilms (15). Clinical trials have indicated that triple therapy containing berberine, amoxicillin, and rabeprazole is non-inferior to bismuth quadruple therapy (eradication rate by PP analysis: 83.6% vs. 85.1%) (16).

Probiotics can alleviate clinical symptoms of H. pylori infection, improve eradication efficacy, and reduce adverse reactions (17). Bio-Three is a standardized triple-strain probiotic preparation consisting of Enterococcus faecalis T-110 (lactic acid bacteria), Clostridium butyricum TO-A (butyric acid-producing bacteria), and Bacillus mesentericus TO-A (saccharifying bacteria). Evidence suggests that Bacillus probiotics, including B. mesentericus (a key constituent of Bio-Three), exert their therapeutic effects by competitively inhibiting pathogens, reinforcing the mucosal barrier, and modulating the host’s immune response (18). These probiotics produce essential metabolites, such as short-chain fatty acids and antimicrobial peptides, which create an unfavorable gastric environment for H. pylori survival and facilitate its clearance (18). Clostridium butyricum also exhibits broad efficacy against Clostridioides difficile, H. pylori, and antibiotic-resistant Escherichia coli, serving as a potential antimicrobial-resistance (AMR) countermeasure (19). Treatment with Clostridium butyricum, Bacillus coagulans, or a combination of both effectively inhibits H. pylori and minimizes adverse reactions, reducing antibiotic resistance burdens (20).

For patients with treatment-resistant FD who have undergone multiple antibiotic regimens, the efficacy of non-antibiotic therapies remains unclear. Limited research exists on non-antibiotic approaches for H. pylori eradication failure, particularly complete non-antibiotic combinations. Therefore, a retrospective analysis was conducted on FD patients with prior H. pylori eradication failures who opted for a 14-day non-antibiotic therapy. The study aimed to assess the efficacy and safety of non-antibiotic triple therapy comprising Weisu granules, berberine hydrochloride, and Bio-Three (containing Clostridium butyricum TO-A, Enterococcus faecalis T-110, and Bacillus mesentericus TO-A) as a rescue treatment for H. pylori infection in FD patients.

To the best of our knowledge, this is the first observational study to evaluate the efficacy of a complete non-antibiotic regimen as a rescue treatment for patients with H. pylori eradication failure and FD. Our findings reveal an overall eradication rate of 72.9% and a clinical symptom relief rate of 77.08% with non-antibiotic triple therapy, alongside an 8.3% incidence of adverse events. This study confirms the potential of non-antibiotic triple therapy as an alternative for managing standard antibiotic-resistant H. pylori infection in FD patients, with high tolerability and compliance, as depicted in Figure 2.

As the efficacy of the current recommended first-line bismuth-based quadruple therapy has gradually decreased, the proportion of patients experiencing multiple eradication failures has increased (21, 22). Even with drug sensitivity testing for rescue treatment, antibiotics face significant challenges (23). In China, the resistance rate of H. pylori to amoxicillin is generally low (0–5%) (24). Consequently, several studies have suggested that high-dose dual therapy, combining a PPI or a potassium-competitive acid blocker (P-CAB) with amoxicillin, represents a promising and safe treatment option (25–27). However, regional variations are significant. In the present study, antibiotics were not used as a rescue treatment because the amoxicillin resistance rate of H. pylori in Guizhou Province has been reported as high as 13.27% (28). The disparity between national figures and Guizhou’s resistance rate may be attributed to the widespread and often unregulated use of amoxicillin for respiratory and gastrointestinal infections in this region, leading to increased primary resistance. This elevated local resistance suggests that standard dual therapies may be less effective in our patient population, warranting exploration of non-antibiotic alternatives such as Weisu granules, berberine, and Bio-Three. Furthermore, a meta-analysis showed that both high-dose dual therapy and guideline-recommended rescue therapies achieved comparable efficacy (81.3% vs. 81.5%, relative risk [RR] 1.00, 95% confidence interval [CI] 0.93–1.08) (29). Additionally, the patients included in this study had previously failed to respond to antibiotic therapy on two or more occasions.

A systematic review and meta-analysis have indicated that traditional Chinese medicine combined with western medicine yields higher eradication and symptom relief rates compared to western medicine alone, with acceptable safety profiles (30). Consequently, there is increasing attention on the eradication efficacy of non-antibiotic drugs against H. pylori. The total eradication rate of H. pylori with the non-antibiotic triple therapy in our study (72.9%) was comparable to or even higher than the efficacy of bismuth-based quadruple therapy (BQT) as a rescue treatment in previous meta-analyses (23), suggesting its potential as an alternative for standard antibiotic-resistant H. pylori infection in our region. Subgroup analyses of patients who had previously failed eradication twice and three times revealed eradication rates of 76.5 and 64.3%, respectively. Although the numerical rate was higher in the double-failure group, the difference was not statistically significant (p = 0.613). These results suggest that non-antibiotic therapy maintains comparable efficacy regardless of the number of prior antibiotic treatment failures. This highlights its potential as a versatile rescue treatment for refractory H. pylori infections in our region, even for the most difficult-to-treat patients who have failed multiple conventional regimens.

Moreover, demographic and clinical data analysis demonstrated that this regimen’s efficacy was unaffected by factors such as gender, smoking or drinking habits, BMI, previous treatment frequency, and family history of gastric cancer, suggesting its suitability for patients with diverse H. pylori eradication histories. Thus, in the face of high antibiotic resistance rates, the lack of antibiotic sensitivity testing, and patients with multiple comorbidities unsuitable for various antibiotics, the non-antibiotic triple therapy utilized in this study represents an effective alternative for patients with H. pylori eradication failure. However, given the small sample size and the single-arm, retrospective design of this study, further multicenter, prospective randomized controlled trials may be necessary to validate the regimen’s effectiveness.

The pathogenesis of FD involves multiple factors, including H. pylori infection (4). Evidence suggests that eradicating H. pylori can lead to improvements in FD symptoms (6). Numerous studies have demonstrated that Chinese herbal medicines or probiotics used in H. pylori treatment can not only enhance eradication rates but also alleviate FD symptoms and reduce adverse reactions (17, 30, 31).

A multicenter randomized controlled trial (RCT) conducted in Sichuan Province, China, compared the efficacy of a 14-day high-dose dual therapy (esomeprazole 20 mg g.i.d + amoxicillin 750 mg g.i.d) with standard bismuth quadruple therapy. The symptom relief rates were notable: 57.9% vs. 53.3% were markedly effective; 18.5% vs. 19.8% were effective; 2.8% vs. 4% were ineffective. The combined symptom relief rate was 76.4% (25). Encouragingly, in our study, the total clinical symptom relief rate was 77.08% (markedly effective 33.33% + effective 43.75%), slightly higher than that of the high-dose dual therapy and bismuth quadruple therapy in the aforementioned study. This indicates the effectiveness of our regimen in alleviating symptoms in FD patients with H. pylori infection. Regarding symptom relief, the relief rates for patients with two prior failures (79.41%) and three prior failures (71.43%) were numerically different; however, this difference was not statistically significant (p > 0.05). Consequently, these findings suggest that the clinical efficacy of the non-antibiotic regimen in alleviating symptoms is consistent and comparable across both groups, regardless of prior eradication attempts.

Furthermore, our analysis of the correlation between H. pylori eradication and FD symptom improvement found that successful eradication did not significantly improve FD symptoms compared to patients without eradication. This could be attributed to the small sample size of our study and the multifactorial nature of FD pathogenesis, which extends beyond H. pylori (4). Further confirmation through well-designed prospective large-sample studies is warranted.

Poor patient compliance is a significant contributor to treatment failure, with adverse events being a key deterrent (32). In our study, the incidence of adverse reactions was only 8.3%, with all events being mild and self-resolving. This incidence was lower than that with the standard antibiotic bismuth quadruple regimen and comparable to that with high-dose dual therapy (33). Patient compliance was generally good, with only four out of 48 patients taking less than 80% of the medication. Most patients tolerated the regimen well, with only one patient discontinuing treatment due to adverse reactions. Thus, our non-antibiotic therapy represents a relatively safe alternative for rescue treatment.

Our study is subject to several limitations that warrant careful consideration when interpreting the results. First and foremost, the study utilizes a retrospective, single-arm design without a control group. This design inherently limits our ability to draw definitive causal inferences about the intervention’s efficacy. This is particularly critical regarding the secondary endpoint of symptom improvement; given that Functional Dyspepsia is characterized by a fluctuating clinical course and is highly susceptible to the placebo effect, the symptom relief observed in this cohort cannot be unequivocally attributed solely to the pharmacological effects of the non-antibiotic regimen. Second, the sample size (N = 48) is relatively small. While sufficient for an exploratory, hypothesis-generating analysis, it limits the study’s statistical power and restricts the generalizability of the findings to the broader population of patients with refractory H. pylori infection. The small sample size also necessitates caution when interpreting subgroup analyses (e.g., comparing outcomes between patients with 2 versus 3 prior failures), as these findings may lack statistical robustness.

Third, we acknowledge the potential influence of heterogeneity in prior treatment exposure. The participants had failed varying combinations of antibiotic regimens before enrollment. This heterogeneity in prior antibiotic exposure could lead to diverse baseline variations in gut microbiota composition and bacterial resistance profiles, acting as a potential confounding factor that was not controlled for in this analysis. Finally, the study was conducted at two centers within a single region (Guizhou Province). Consequently, regional factors, including specific dietary habits and local characteristics of H. pylori strains, may influence the external validity of the results. Future research should prioritize multi-center, randomized controlled trials with larger sample sizes and long-term follow-up to validate these preliminary findings and rigorously assess the clinical utility of this non-antibiotic approach.

In summary, the non-antibiotic regimen holds promise as an effective alternative for patients with FD who are afflicted by standard antibiotic-resistant H. pylori infection, demonstrating notable rates of H. pylori eradication and symptom improvement. In contrast to antibiotic therapies, non-antibiotic approaches offer multifaceted, multi-target antibacterial effects, which are less prone to inducing drug resistance. They obviate the need to consider prior antibiotic exposure or conduct antibiotic sensitivity tests and entail a lower incidence of adverse reactions. Additionally, non-antibiotic interventions may reduce inflammation and facilitate mucosal repair. Future investigations should examine their underlying mechanisms or conduct multi-center, large-scale, randomized controlled clinical trials to validate their long-term efficacy and assess their role in current treatment strategies.