Review for 10.1186/s12876-025-03819-w (2025)

Title: The Double-Edged Sword: Impact of Antibiotic Use on Immunotherapy Efficacy in
Advanced Hepatocellular Carcinoma
Version: 2 Date: 08 Mar 2025
Reviewer:  Mohamed H. Zidan
Reviewer's report:
Dear Author,
Re: The Double-Edged Sword: Impact of Antibiotic Use on Immunotherapy Efficacy in
Advanced Hepatocellular Carcinoma
Thank you for the opportunity to review this important and clinically relevant study. The
manuscript presents a retrospective analysis exploring the impact of antibiotic use on the efficacy
of immune checkpoint inhibitors in patients with advanced hepatocellular carcinoma. This
is a timely and significant topic, as immune checkpoint inhibitors are increasingly used in
oncology, and the role of antibiotic-induced gut microbiota alterations remains an area of active
investigation.  The study is methodologically well-designed, with clear inclusion and exclusion
criteria, appropriate statistical analyses, and a logical presentation of results.
While the manuscript is robust in its approach, there are several areas where improvements could
enhance clarity:
In the introduction, the manuscript provides a comprehensive background on hepatocellular
carcinoma and immune checkpoint inhibitors but would benefit from a more direct discussion
on how gut microbiota influences immunotherapy efficacy. While relevant studies are cited, a
clearer focus on the microbiota's immunomodulatory effects and its role in shaping responses
to immune checkpoint inhibitors would strengthen the narrative.
While electronic medical records were used for data collection, details on how missing data were
handled should be included. The manuscript states that follow-ups were conducted via telephone
interviews and electronic records, but it does not clarify how the loss to follow-up cases was
managed or accounted for in survival analyses.
The results section presents key findings clearly, but an additional explanation of the statistical
tables would improve reader comprehension. In Table 1, the differences between the antibiotic
and non-antibiotic groups should be explicitly discussed in the text rather than left for the reader
to interpret. Table 2 highlights significant differences in progression-free survival for patients
with intra-abdominal infections in the univariate analysis (p=0.037), but the loss of significance
in the multivariate model (p=0.123) warrants further discussion. Table 3 shows a significant
association between antibiotic use for other indications and overall survival (p=0.032), yet this
finding is not sufficiently emphasized in the results discussion. Expanding on these results and
their potential implications would improve the manuscript’s clarity.
The discussion is well-structured but would benefit from a deeper exploration of potential
mechanisms underlying the observed effects. While the study acknowledges the gut microbiota’s
role in immunotherapy outcomes, a more detailed explanation of how specific microbial species
influence immune checkpoint inhibitor efficacy would add scientific rigor. The potential role
of inflammatory cytokines and immune microenvironment alterations should also be discussed
in more depth. Furthermore, while the limitations section notes the retrospective nature of the
study and the potential for confounding factors, it does not address the impact of comorbidities
such as diabetes or cirrhosis, which could influence both antibiotic use and immune function.
Acknowledging these potential confounders would strengthen the study's validity.
There are minor grammatical and stylistic issues throughout the manuscript that affect
readability. Some sentences are overly complex, while others could be more concise. For
instance, the phrase "Given that the liver, an organ with a unique immune microenvironment, is
particularly responsive to immunotherapy, there is great potential for immunotherapy in patients
with advanced HCC" could be restructured for clarity and conciseness. A thorough language
revision would improve the manuscript’s overall readability.
I appreciate the opportunity to review this work and look forward to seeing the revised version.
Sincerely,