Management of Helicobacter pylori infection: the Maastricht VI/Florence consensus report

Probiotics Prescribed With Helicobacter pylori Eradication Therapy in Europe: Usage Pattern, Effectiveness, and Safety. Results From the European Registry on Helicobacter pylori Management (Hp-EuReg)

INTRODUCTION

To evaluate the prescription patterns, effectiveness, and safety of adding probiotics to Helicobacter pylori eradication therapy, in Europe.

METHODS

International, prospective, noninterventional registry of the clinical practice of the European gastroenterologists. Data were collected and quality reviewed until March 2021 at AEG-REDCap. The effectiveness was evaluated by modified intention-to-treat analysis, differentiating by geographic areas. Adverse events (AEs) were categorized as mild, moderate, and severe.

RESULTS

Overall, 36,699 treatments were recorded, where 8,233 (22%) were prescribed with probiotics. Probiotics use was associated with higher effectiveness in the overall analysis (odds ratio [OR] 1.631, 95% confidence interval [CI] 1.456-1.828), as well as in triple (OR 1.702, 95% CI 1.403-2.065), quadruple (OR 1.383, 95% CI 0.996-1.920), bismuth quadruple (OR 1.248, 95% CI 1.003-1.554), and sequential therapies (OR 3.690, 95% CI 2.686-5.069). Lactobacillus genus was associated with a higher therapy effectiveness in Eastern Europe when triple (OR 2.625, 95% CI 1.911-3.606) and bismuth quadruple (OR 1.587, 95% CI 1.117-2.254) first-line therapies were prescribed. In Central Europe, the use of probiotics was associated with a decrease in both the overall incidence of AEs (OR 0.656, 95% CI 0.516-0.888) and severe AEs (OR 0.312, 95% CI 0.217-0.449). Bifidobacterium genus was associated with lower overall (OR 0.725, 95% CI 0.592-0.888) and severe (OR 0.254, 95% CI 0.185-0.347) AEs, and Saccharomyces was associated with reduced overall (OR 0.54, 95% CI 0.32-0.91) and severe (OR 0.257, 95% CI 0.123-0.536) AEs under quadruple-bismuth regimen.

DISCUSSION

In Europe, the use of probiotics was associated with higher effectiveness and safety of H. pylori eradication therapy. Lactobacillus improved treatment effectiveness, whereas Bifidobacterium and Saccharomyces were associated with a better safety profile.

Targeting Helicobacter pylori Through the "Muco-Microbiotic Layer" Lens: The Challenge of Probiotics and Microbiota Nanovesicles

The muco-microbiotic layer represents a critical biological frontier in gastroenterology, emphasizing the intricate interplay between the protective mucus, its resident microbiota, and extracellular vesicles. This review explores the functional morphology of the gastric mucosa, focusing on the gastric muco-microbiotic layer, its role as a protective barrier, and its dynamic interaction with some of the most insidious pathogens such as Helicobacter pylori (H. pylori). Highlighting the multifaceted mechanisms of H. pylori pathogenesis, we have delved into bacterial virulence factors, host immune responses, and the microbiota's regulatory effects. Novel therapeutic strategies for H. pylori eradication, including traditional antibiotic therapies and emerging adjuvant treatments like probiotics and probiotic-derived extracellular vesicles, are critically examined. These findings underscore the potential of targeting nanovesicular interactions in the gastric mucosa, proposing a paradigm shift in the management of H. pylori infections to improve patient outcomes while mitigating antibiotic resistance.

Management of Patients With Refractory Reflux-Like Symptoms Despite Proton Pump Inhibitor Therapy: Evidence-Based Consensus Statements

BACKGROUND

Many patients diagnosed with gastro-oesophageal reflux disease (GERD) have persistent symptoms despite proton pump inhibitor (PPI) therapy.

AIMS

The aim of this consensus is to provide evidence-based statements to guide clinicians caring for patients with refractory reflux-like symptoms (rRLS) or refractory GERD.

METHODS

This consensus was developed by the International Working Group for the Classification of Oesophagitis. The steering committee developed specific PICO questions pertaining to the management of PPI rRLS. Methodologists conducted systematic reviews of the literature. The quality of evidence and strength of recommendations were rated using the GRADE approach.

RESULTS

Consensus was reached on 13 of 17 statements on diagnosis and management. For rRLS, suggested diagnostic strategies included endoscopy, ambulatory reflux testing and oesophageal manometry. The group did not reach consensus on the role of oesophageal biopsies or the use of reflux-symptom association in patients undergoing reflux testing. The group suggested against increasing the PPI dose in patients who had received 8 weeks of a twice-daily PPI. Adjunctive alginate or antacid therapy was suggested. There was no consensus on the role of adjunctive prokinetics. There was little role for adjunctive transient lower oesophageal sphincter relaxation (TLESR) inhibitors or bile acid sequestrants. Endoscopic or surgical anti-reflux procedures should not be performed in patients with rRLS in the absence of objectively confirmed GERD.

CONCLUSIONS

The management of rRLS should be personalised, based on shared decision-making regarding the role of diagnostic testing to confirm or rule out GERD as a basis for treatment optimisation. Anti-reflux procedures should not be performed without objective confirmation of GERD.

Multidisciplinary Approach Improves Eradication Rate and Safety in Refractory Helicobacter pylori Infection

INTRODUCTION

Helicobacter pylori (HP) infection is prevalent worldwide and contributes to various gastrointestinal diseases. Eradication therapy is crucial in managing HP infection, but antibiotic resistance has led to refractory cases, complicating treatment outcomes and increasing the risk of adverse events. This study aimed to evaluate the effectiveness of a multidisciplinary approach, termed HP Multidisciplinary Team (MDT) Clinic, in improving eradication rates and safety in patients with refractory HP infection.

METHODS

Between November 2020 and November 2023, 153 patients with refractory HP infection were included, with 51 patients in the non-HP-MDT group and 102 patients in the HP-MDT group. The HP-MDT clinic provided personalized treatment plans, patient education, and follow-up. Genetic testing was conducted in selected cases to assess resistance patterns.

RESULTS

Patients attending the HP-MDT clinic showed significantly higher eradication rates compared with those in the non-HP-MDT group (80.39% vs 50.98%, P < 0.001). Logistic regression analysis confirmed that HP-MDT clinic attendance was independently associated with higher eradication rates (odds ratio: 4.43, 95% CI: 2.02 to 9.71, P < 0.001). Genetic testing revealed high rates of antibiotic resistance, particularly to clarithromycin (10/11, 90.91%) and metronidazole (11/11, 100%). Despite resistance, the HP-MDT approach achieved a high eradication rate of 92.31%. Adverse drug reactions occurred in 12.75% of patients in the HP-MDT group, predominantly mild gastrointestinal symptoms.

DISCUSSION

The HP-MDT clinic, integrating medical, pharmaceutical, and nursing expertise, significantly improved eradication rates and safety in patients with refractory HP infection. Personalized treatment plans, patient education, and genetic testing contributed to successful outcomes with minimal adverse events.

International consensus statement on microbiome testing in clinical practice

There is growing interest in the potential exploitation of the gut microbiome as a diagnostic tool in medicine, but evidence supporting its clinical usefulness is scarce. An increasing number of commercial providers offer direct-to-consumer microbiome diagnostic tests without any consensus on their regulation or any proven value in clinical practice, which could result in considerable waste of individual and health-care resources and potential drawbacks in the clinical management of patients. We convened an international multidisciplinary expert panel to standardise best practices of microbiome testing for clinical implementation, including recommendations on general principles and minimum requirements for their provision, indications, pre-testing protocols, method of analyses, reporting of results, and potential clinical value. We also evaluated current knowledge gaps and future directions in this field. We aimed to establish a framework to regulate the provision of microbiome testing and minimise the use of inappropriate tests and pave the way for the evidence-based development and use of human microbiome diagnostics in clinical medicine.

Real-Time Assessment of H. pylori Infection to Guide Molecular Antibiotic Resistance Testing: A Combined Endoscopy-Gastric Juice Analysis Approach

BACKGROUND

Helicobacter pylori antibiotic resistance is the most relevant cause of treatment failure. Antibiotic susceptibility testing (AST) allows for selecting the appropriate eradication regimen.

AIMS

To assess the diagnostic accuracy of gastric aspirate-based genotypic AST (G-AST) for detecting clarithromycin and levofloxacin resistance compared with conventional phenotypic AST (P-AST).

METHODS

We recruited 461 consecutive patients scheduled for endoscopy. H. pylori was detected intraprocedurally using Endofaster, a novel method combining endoscopy with gastric juice analysis. For H. pylori-positive patients, we collected gastric aspirates and biopsies. G-AST was performed using DNA extracted from aspirates, with Sanger sequencing to detect polymorphisms in the 23S rRNA and gyrA genes associated, respectively, with resistance to macrolides and fluoroquinolones. P-AST was performed on H. pylori isolated from biopsies using ETEST.

RESULTS

One hundred and seventy-eight (40.4%) patients tested positive for H. pylori during endoscopy. Paired gastric biopsies and aspirates were available from 152 H. pylori-positive patients. By P-AST, resistance rates were 15.1% (23/152) for clarithromycin and 18.4% (28/152) for levofloxacin. G-AST showed a high level of agreement with P-AST for clarithromycin (kappa 0.86) and levofloxacin (kappa 0.81) resistance and diagnostic accuracy of 97% and 95%, respectively.

CONCLUSIONS

The novel method combining endoscopy with immediate intraprocedural gastric juice analysis for the detection of H. pylori, followed by AST in case of a positive finding, is valid and practical for tailoring eradication regimens for H. pylori infection. Genotypic AST from gastric aspirates is highly accurate for detecting clarithromycin and levofloxacin resistances.

Investigation of metronidazole resistance-associated mutations and virulence genotypes in helicobacter pylori isolates from the Egyptian population: A cross-sectional study

INTRODUCTION

This cross-sectional study assesses the prevalence of metronidazole resistance-associated mutations and virulence genotypes in Helicobacter pylori (H. pylori) strains isolated from the Egyptian population. H. pylori infection is a significant public health concern, with antibiotic resistance challenging its eradication.

METHODS

Gastric biopsy samples were collected from symptomatic patients referred for upper gastrointestinal endoscopy at selected healthcare facilities. The study included 250 participants with symptoms suggestive of H. pylori infection and aged 18 years or older. Biopsy samples were obtained using standard endoscopic techniques, and H. pylori strains were isolated and identified in the laboratory. Antimicrobial susceptibility testing was conducted using standard methods. Molecular analysis, including polymerase chain reaction (PCR) and sequencing, was performed to identify metronidazole resistance-associated mutations (rdxA and frxA) and virulence genotypes (cagA and vacA).

RESULTS

Antimicrobial susceptibility testing revealed that 43.6 % of the isolates were resistant to metronidazole, while 11.8 %, 4.5 %, and 55.4 % were resistant to clarithromycin, amoxicillin, and levofloxacin. Molecular analysis identified rdxA and frxA mutations in 36.3 % and 31.8 % of the isolates, respectively, indicating metronidazole resistance-associated mutations. Additionally, 60.0 % of the isolates were positive for the cagA gene, and 80.0 % had the vacA s1 type, both associated with increased virulence. A significant association was found between metronidazole resistance and the presence of cagA gene, vacA s1 type, rdxA mutation, and frxA mutation. Statistical analysis revealed associations between specific mutations and virulence genotypes with respective odds ratios, indicating higher likelihoods of metronidazole resistance in isolates exhibiting these genetic characteristics.

CONCLUSIONS

This study highlights the prevalence of metronidazole resistance and the association between specific mutations and virulence genotypes in H. pylori strains isolated from the Egyptian population. The findings underscore the importance of monitoring antibiotic resistance patterns and understanding the genetic determinants of virulence in H. pylori for effective management and treatment strategies.

Surgical Therapy of Gastric Ulcer Disease

Medical advancements, including Helicobacter pylori eradication and antisecretory agents, have reduced peptic ulcer disease (PUD)-associated hospital admissions, mortality, and surgical interventions over the past 30 years. Surgery plays an important role in the treatment of life-threatening complications of PUD, such as bleeding, perforation, and gastric outlet obstruction, as well as for disease that is refractory to medical management. The article highlights the critical role of surgery in cases where medical therapy is insufficient or in the event of emergency complications arising from PUD.

Comparison of tegoprazan and proton pump inhibitors for first-line Helicobacter pylori eradication: a systematic review with meta-analysis

BACKGROUND

Tegoprazan (TPZ), a potassium-competitive acid blocker with potent gastric acid-suppressing activity, may be a potential agent for treating Helicobacter pylori infection. The study aimed to evaluate the efficacy of TPZ-based therapy for H. pylori eradication compared with proton pump inhibitor (PPI)-based therapy.

RESEARCH DESIGN AND METHODS

A comprehensive literature search was conducted up to August 2024 using PubMed, Embase, and the Cochrane Library to investigate the beneficial effects of TPZ-based therapy for H. pylori eradication. Studies that evaluated the eradication rates between the TPZ- and PPI-based therapies were included. The authors conducted a meta-analysis to calculate the eradication rate and pooled risk ratio (RR) with a 95% confidence interval.

RESULTS

Seven studies involving 3200 patients were included. H. pylori eradication rates did not differ significantly between the TPZ- and PPI-based therapies based on the intention-to-treat (77.3% vs. 76.4%, p = 0.68; pooled RR = 1.01 [0.97-1.05]) and per-protocol (84.3% vs. 84.2%, p = 0.69; pooled RR = 1.01 [0.98-1.04]) analyses. Additionally, no significant difference was observed in the adverse drug events between TPZ- and PPI-based therapies (27.2% vs. 30.8%, p = 0.26; pooled RR = 0.91 [0.76-1.08]).

CONCLUSIONS

H. pylori eradication and adverse drug event rates with TPZ- and PPI-based treatments were similar.

Prevalence of Endoscopic and Histological Lesions at Upper Endoscopy: A Cross-Sectional, Multicentre Study in Clinical Practice

Background/Aim

Prevalence of gastroduodenal endoscopic and histological lesions may modify over time due to different factors. We assessed both macroscopic and histological lesions currently detected at upper endoscopy performed in routine practice.

Patients and Methods

Clinical, endoscopic, and histological data of consecutive adult patients referred for upper endoscopy in the 28 participating centres were analysed. Only patients who underwent the first endoscopic examination were considered. Prevalence of erosive/ulcerative lesions, cancers and extensive precancerous lesions in the stomach, and Helicobacter pylori infection was computed.

Results

A total of 1,431 patients underwent endoscopy for gastro-oesophageal reflux symptoms (31.5%), dyspepsia (29.4%), or alarm symptoms (18.5%). Erosive oesophagitis or Barrett's oesophagus was detected in 210 (14.7%) cases, peptic ulcer in 49 (3.4%), and a neoplastic lesion in 17 (1.2%). H. pylori was present in 201 (22.6%) cases, and extensive precancerous lesions on gastric mucosa in 46 (5.6%) patients. Gastric lesions were more prevalent in patients aged ≥50 years (26% vs. 18%; p = 0.001), and peptic ulcers were more frequently detected in patients with H. pylori (9.4% vs. 2.3%; p = 0.001) and in males (5.8% vs. 1.6%; p = 0.001), while neoplastic lesions in patients with alarm symptoms (3.8% vs. 0.6%; p = 0.001).

Conclusions

The overall endoscopic lesions were more prevalent in patients aged ≥50 years, peptic ulcer and erosions were more frequent in H. pylori-infected patients, and extensive gastric precancerous lesions were present in less than 6% of cases.

AGA Clinical Practice Update on Screening and Surveillance in Individuals at Increased Risk for Gastric Cancer in the United States: Expert Review

DESCRIPTION

Gastric cancer (GC) is a leading cause of preventable cancer and mortality in certain US populations. The most impactful way to reduce GC mortality is via primary prevention, namely Helicobacter pylori eradication, and secondary prevention, namely endoscopic screening and surveillance of precancerous conditions, such as gastric intestinal metaplasia (GIM). An emerging body of evidence supports the possible impact of these strategies on GC incidence and mortality in identifiable high-risk populations in the United States. Accordingly, the primary objective of this American Gastroenterological Association (AGA) Clinical Practice Update (CPU) Expert Review is to provide best practice advice for primary and secondary prevention of GC in the context of current clinical practice and evidence in the United States.

METHODS

This CPU Expert Review was commissioned and approved by the AGA Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Gastroenterology. These best practice advice statements were drawn from a review of the published literature and expert opinion. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: There are identifiable high-risk groups in the United States who should be considered for GC screening. These include first-generation immigrants from high-incidence GC regions and possibly other non-White racial and ethnic groups, those with a family history of GC in a first-degree relative, and individuals with certain hereditary gastrointestinal polyposis or hereditary cancer syndromes. BEST PRACTICE ADVICE 2: Endoscopy is the best test for screening or surveillance in individuals at increased risk for GC. Endoscopy enables direct visualization to endoscopically stage the mucosa and identify areas concerning for neoplasia, as well as enables biopsies for further histologic examination and mucosal staging. Both endoscopic and histologic staging are key for risk stratification and determining whether ongoing surveillance is indicated and at what interval. BEST PRACTICE ADVICE 3: High-quality upper endoscopy for the detection of premalignant and malignant gastric lesions should include the use of a high-definition white-light endoscopy system with image enhancement, gastric mucosal cleansing, and insufflation to achieve optimal mucosal visualization, in addition to adequate visual inspection time, photodocumentation, and use of a systematic biopsy protocol for mucosal staging when appropriate. BEST PRACTICE ADVICE 4: H pylori eradication is essential and serves as an adjunct to endoscopic screening and surveillance for primary and secondary prevention of GC. Opportunistic screening for H pylori infection should be considered in individuals deemed to be at increased risk for GC (refer to Best Practice Advice 1). Screening for H pylori infection in adult household members of individuals who test positive for H pylori (so-called "familial-based testing") should also be considered. BEST PRACTICE ADVICE 5: In individuals with suspected gastric atrophy with or without intestinal metaplasia, gastric biopsies should be obtained according to a systematic protocol (eg, updated Sydney System) to enable histologic confirmation and staging. A minimum of 5 total biopsies should be obtained, with samples from the antrum/incisura and corpus placed in separately labeled jars (eg, jar 1, "antrum/incisura" and jar 2, "corpus"). Any suspicious areas should be described and biopsied separately. BEST PRACTICE ADVICE 6: GIM and dysplasia are endoscopically detectable. However, these findings often go undiagnosed when endoscopists are unfamiliar with the characteristic visual features; accordingly, there is an unmet need for improved training, especially in the United States. Artificial intelligence tools appear promising for the detection of early gastric neoplasia in the adequately visualized stomach, but data are too preliminary to recommend routine use. BEST PRACTICE ADVICE 7: Endoscopists should work with their local pathologists to achieve consensus for consistent documentation of histologic risk-stratification parameters when atrophic gastritis with or without metaplasia is diagnosed. At a minimum, the presence or absence of H pylori infection, severity of atrophy and/or metaplasia, and histologic subtyping of GIM, if applicable, should be documented to inform clinical decision making. BEST PRACTICE ADVICE 8: If the index screening endoscopy performed in an individual at increased risk for GC (refer to Best Practice Advice 1) does not identify atrophy, GIM, or neoplasia, then the decision to continue screening should be based on that individual's risk factors and preferences. If the individual has a family history of GC or multiple risk factors for GC, then ongoing screening should be considered. The optimal screening intervals in such scenarios are not well defined. BEST PRACTICE ADVICE 9: Endoscopists should ensure that all individuals with confirmed gastric atrophy with or without GIM undergo risk stratification. Individuals with severe atrophic gastritis and/or multifocal or incomplete GIM are likely to benefit from endoscopic surveillance, particularly if they have other risk factors for GC (eg, family history). Endoscopic surveillance should be considered every 3 years; however, intervals are not well defined and shorter intervals may be advisable in those with multiple risk factors, such as severe GIM that is anatomically extensive. BEST PRACTICE ADVICE 10: Indefinite and low-grade dysplasia can be difficult to reproducibly identify by endoscopy and accurately diagnose on histopathology. Accordingly, all dysplasia should be confirmed by an experienced gastrointestinal pathologist, and clinicians should refer patients with visible or nonvisible dysplasia to an endoscopist or center with expertise in the diagnosis and management of gastric neoplasia. Individuals with indefinite or low-grade dysplasia who are infected with H pylori should be treated and have eradication confirmed, followed by repeat endoscopy and biopsies by an experienced endoscopist, as visual and histologic discernment may improve once inflammation subsides. BEST PRACTICE ADVICE 11: Individuals with suspected high-grade dysplasia or early GC should undergo endoscopic submucosal dissection with the goal of en bloc, R0 resection to enable accurate pathologic staging with curative intent. Eradication of active H pylori infection is essential, but should not delay endoscopic intervention. Endoscopic submucosal dissection should be performed at a center with endoscopic and pathologic expertise. BEST PRACTICE ADVICE 12: Individuals with a history of successfully resected gastric dysplasia or cancer require ongoing endoscopic surveillance. Suggested surveillance intervals exist, but additional data are required to refine surveillance recommendations, particularly in the United States. BEST PRACTICE ADVICE 13: Type I gastric carcinoids in individuals with atrophic gastritis are typically indolent, especially if <1 cm. Endoscopists may consider resecting gastric carcinoids <1 cm and should endoscopically resect lesions measuring 1-2 cm. Individuals with type I gastric carcinoids >2 cm should undergo cross-sectional imaging and be referred for surgical resection, given the risk of metastasis. Individuals with type I gastric carcinoids should undergo surveillance, but the intervals are not well defined. BEST PRACTICE ADVICE 14: In general, only individuals who are fit for endoscopic or potentially surgical treatment should be screened for GC and continued surveillance of premalignant gastric conditions. If a person is no longer fit for endoscopic or surgical treatment, then screening and surveillance should be stopped. BEST PRACTICE ADVICE 15: To achieve health equity, a personalized approach should be taken to assess an individual's risk for GC to determine whether screening and surveillance should be pursued. In conjunction, modifiable risk factors for GC should be distinctly addressed, as most of these risk factors disproportionately impact people at high risk for GC and represent health care disparities.

Diagnostic immunohistochemistry use in Belgian laboratories

OBJECTIVES

In Belgium, the use of IHC testing has grown in the last decade. However, there is a lack of information on the specific indications for which it is reimbursed. The aim of the study is to offer an overview on the use of diagnostic inmunohistochemistry (IHC) testing and its recent trends.

METHODS

Our analysis is limited to reimbursed use, which in Belgium is restricted to a maximum of 4 different IHC stains per sampling session for diagnostic IHC. Consulted sources included data from the compulsory health insurance, and data extracted from a sample of pathology reports gathered from Belgian laboratories for the year 2019.

RESULTS

Over the last 10 years, the use of IHC in Belgium grew from 729 030 stains in 2012 to 1,194,331 in 2019, an increase of 63.8 % while the increase in the number of histological or cytological examinations was 13.3 %. The main stains used in 2019 were H. pylori, Ki-67 and broad spectrum CK, which were used in multiple body sites, reflecting the difficulties to identify specific indications. The gastro-intestinal tract is the body site with the highest number of IHC stains (38.2 % of all stains performed), and the most frequently used stain in gastro intestinal biopsies were H. pylori (43.1 %), and CD3 (6.8 %).

CONCLUSION

This study offers an overview of the most frequent indications for which diagnostic IHC staining is used in Belgium, and reflects the evolving nature of this field, highlighting the importance to increase clarity and improve data collection.

Endoscopic Screening and Surveillance of Gastrointestinal Cancer

Gastrointestinal (GI) cancer is a major health concern, contributing significantly to mortality rates in many regions, including Europe. It affects millions of people worldwide and leads to hundreds of thousands of deaths each year. Early detection and treatment through endoscopic methods play a vital role, providing less invasive and more affordable options compared to traditional surgical procedures. Targeted screening is vital for conditions such as Barrett's esophagus (BE), esophageal adenocarcinoma (EAC), gastric cancer (GC), ampullary carcinoma (AC), and colorectal cancer (CRC), particularly in high-risk populations. Endoscopic surveillance significantly reduces cancer incidence and improves survival rates, highlighting the importance of continuous advancements and updated guidelines to enhance screening efficacy and patient outcomes.

Prevalence and antimicrobial resistance of highly virulent cagA-positive Helicobacter pylori strains in Southern Poland

PURPOSE

Assessment of Helicobacter pylori (H. pylori) prevalence in Southern Poland, focusing on highly virulent cagA-positive strains associated with gastric cancer risk, along with analysis of antimicrobial resistance and its molecular mechanisms.

METHODS

A total of 130 dyspeptic patients, who underwent endoscopy, were enrolled in the study. Presence of H. pylori in gastric mucosa biopsy specimens was confirmed by rapid urease tests, histological examination, culture, and molecular assays. Antimicrobial susceptibility was tested using the E-test, while the cagA gene (virulence marker) was identified by PCR. The GenoType HelicoDR detected mutations for resistance to clarithromycin (23 S rRNA) and levofloxacin (gyrA). Resistance to rifampicin and levofloxacin was investigated by sequencing the rpoB and gyrA genes.

RESULTS

H. pylori prevalence in Southern Poland was 30.8%, with 60% of infections involving cagA-positive strains. Susceptibility testing revealed resistance rates of 22.9% for metronidazole, 14.3% for clarithromycin, 11.4% for levofloxacin and 25.7% for rifampicin. Among the 24 cagA-positive strains, 45.8% were resistant to at least one antibiotic. Clarithromycin resistance was caused by A2143G mutation. The gyrA gene sequence showed the N87K mutation linked to fluoroquinolone resistance. No mutations were found in the rpoB gene.

CONCLUSION

Infections with multidrug-resistant CagA-positive strains require recommended treatment strategies due to the high risk of progression of infection to gastric cancer.

Comparative analysis of the detection of antibiotic genotypic resistance with gastric mucosa, gastric fluid, and fecal samples in patients with Helicobacter pylori infection

Genotypic methods for detecting antibiotic resistance in Helicobacter pylori infection offer a rapid, convenient, and accurate approach for tailored therapy. However, existing studies predominantly examine single sample types and lack comparative analyses across different samples. This study comprehensively detects and compares genotypic resistance to clarithromycin and levofloxacin in gastric mucosa, gastric fluid, and fecal samples from the same patients. The study enrolled 183 participants, comprising 124 H. pylori-positive and 59 H. pylori-negative patients. All participants provided fecal samples and underwent gastroscopy for the collection of gastric mucosa and gastric fluid. Real-time PCR was employed to detect genotypic resistance to clarithromycin and levofloxacin in conjunction with bacterial culture and antibiotic susceptibility testing. Genotypic resistance detection rates for clarithromycin were 100% in gastric mucosa, 99.2% in gastric fluid, and 79.8% in fecal samples. For levofloxacin, detection rates were 97.6%, 96.8%, and 72.6%, respectively. The results showed that PCR detection for clarithromycin exhibited high sensitivity (0.94-0.95) and specificity (0.88-0.89) across all sample types. However, PCR detection for levofloxacin demonstrated slightly lower sensitivity (0.79-0.89) and specificity (0.79-0.83). The comparison of genotypic resistance results by PCR among the three sample types showed that gastric mucosa and gastric juice exhibited higher consistency, while the consistency between feces and both gastric mucosa and gastric juice was lower. This study confirmed good consistency between genotypic and phenotypic resistance in clarithromycin and levofloxacin. While both gastric mucosa and gastric fluid samples demonstrated high detection performance, the efficiency of detecting fecal samples was constrained by challenges in DNA extraction.

IMPORTANCE

This study, with a large sample size, comprehensively tested both Helicobacter pylori-negative and -positive patients, including rapid urease test, histopathological evaluation and staining, bacterial culture, susceptibility testing, and resistance gene mutation analysis. By simultaneously examining gastric mucosa, gastric juice, and fecal samples from the same individuals, we minimized confounding factors arising from different sample sources, ensuring the reliability of our results. This approach effectively delineated the differences and characteristics in detection performance among different sample types, offering crucial reference data for selecting appropriate detection samples and identifying areas for improvement. The findings revealed robust concordance between genotypic and phenotypic resistance, with both gastric mucosa and gastric juice samples demonstrating excellent detection performance. However, the efficiency of detecting resistance in fecal samples was hampered by challenges in DNA extraction.

The efficacy and safety of Vonoprazan and Tegoprazan in Helicobacter pylori eradication: a comprehensive systematic review and meta-analysis of randomized controlled trials

Background

Potassium-competitive acid blocker (P-CAB)-based therapies are emerging as promising alternatives for eradicating Helicobacter pylori infection. However, the comparative efficacy of P-CAB-based therapy versus proton-pump inhibitor (PPI)-based therapy in treating H. pylori infection remains uncertain.

Objectives

This meta-analysis evaluated the efficacy and safety of P-CAB-based therapies, including Vonoprazan (VPZ) and Tegoprazan (TPZ), compared to PPI-based therapies for H. pylori infection. Subgroup analysis assessed the influence of drug history, experimental drug, treatment duration, combination therapies, and geographic regions on treatment outcomes.

Design

Meta-analysis.

Data sources and methods

Comprehensive searches were conducted in major databases, including PubMed, Embase, the Cochrane Library, and Web of Science, up to January 1, 2024. The primary outcome was the eradication rate, analyzed by intention-to-treat (ITT). Secondary outcomes included adverse events. Heterogeneity among studies was assessed using the χ2 test and the I 2 test. I 2 > 50% or p < 0.05 indicated significant heterogeneity.

Results

The analysis totally included 28 randomized controlled trials (RCTs) comprising 37 studies and 8818 patients diagnosed with H. pylori infection. Of these, 14 RCTs, including 20 studies and 4286 patients, compared P-CAB-based therapy with 14-day bismuth-based quadruple therapy (BQT). P-CAB-based therapy exhibited superior eradication rates compared to both 14-day BQT and PPI-based therapy (ITT analysis: 87.0% vs 79.8%, risk ratio (RR) = 1.08, 95% CI: 1.04-1.12, p < 0.0001; and 85.6% vs 77.8%, RR = 1.09, 95% CI: 1.05-1.12, p < 0.00001, respectively). This enhanced efficacy was particularly pronounced in patients with clarithromycin-resistant infections (73.7% vs 41.5%, RR = 1.53, 95% CI: 1.07-2.20, p = 0.02). Subgroup analysis demonstrated higher eradication rates with P-CAB-based therapy in treatment-naïve participants, VPZ recipients, and those receiving 7- or 14-day regimens (dual, triple, or quadruple therapy). However, no significant differences were observed in treatment-experienced subgroups, TPZ recipients, or those on 10-day regimens. In addition, P-CAB-based therapy showed a lower incidence of adverse events than PPI-based treatments (RR = 0.73, 95% CI: 0.63-0.86, p < 0.0001).

Conclusion

P-CAB-based therapies are more effective than traditional PPI-based treatments for eradicating H. pylori infection, with a reduced incidence of adverse events.

PROSPERO registration

CRD42024503665.

High-dose dual therapy for Helicobacter pylori eradication inducing less impact on the gut microbiota

BACKGROUND

Helicobacter pylori (H. pylori) eradication regimens may have different effects on the gut microbiota. Few studies have analyzed the safety of high-dose dual therapy (HDDT) from a micro-ecological perspective. This study aimed to compare the impact of H. pylori eradication with HDDT and bismuth quadruple therapy (BQT) on gut microbiota.

PATIENTS AND METHODS

H. Pylori-infected treatment-naive patients were recruited and screened from September 2023 to April 2024 and randomly assigned to the HDDT group (esomeprazole 20 mg, amoxicillin 750 mg, qid, 14 days) or BQT group (esomeprazole 20 mg, amoxicillin 1000 mg, clarithromycin 500 mg, and bismuth potassium citrate 600 mg, bid, 14 days). Fresh stool specimens were collected and stored before treatment and at week 2 and week 8 after treatment. The diversity and composition of the gut microbiota were compared and analyzed in both groups using 16 S rRNA gene sequencing.

RESULTS

Forty-nine H. pylori positive patients were enrolled and randomly assigned to either the HDDT (n = 24) or the BQT group (n = 25) group. Compared with baseline, alpha and beta diversities significantly changed at week 2 after receiving BQT and did not recover fully at week 8. However, in the HDDT group, the diversities at week 2 changed mildly without statistical significance, compared to baseline. Additionally, a greater number of species had alterations in their abundances in the BQT group compared to the HDDT group at week 2. However, the abundances of these species were restored to their previous levels at week 8 in both the HDDT and BQT groups.

CONCLUSIONS

Compared to BQT, HDDT exerted less impact on the diversity and composition of the gut microbiota.

CLINICAL TRIAL REGISTRATION

ChiCTR2100053268.

Risks of anti-Helicobacter therapy and long-term therapy with antisecretory drugs

Helicobacter pylori (H. pylori) infection has a protective effect on gastroesophageal reflux disease (GERD). Both of these diseases have a very high incidence and prevalence. As a result, GERD often recurs after anti-Helicobacter therapy. The problem of effective treatment of H. pylori infection and GERD is that the main groups of drugs [proton pump inhibitors (PPIs) and potassium-competitive acid blockers] have the possibility of side effects with use. Such supposed side effects have no evidence in randomized controlled trials that comply with the principles of evidence-based medicine. Morphological changes in the gastric mucosa after long-term use of antisecretory drugs should be considered as compensatory mechanisms of sanogenesis. The greatest concern for doctors who treat patients with antisecretory drugs is the risk of gastric carcinogenesis. This article presents an analysis of morphological and pathophysiological changes that occur after long-term use of antisecretory drugs (PPIs). Hypertrophy (hyperplasia) of G cells, enterochromaffin-like cells and possible fundic gland polyps (hyperplasia) are compensatory mechanisms of sanogenesis during long-term treatment with PPIs. These mechanisms are of primary importance for rehabilitation and prevention of complications in patients with GERD, non-steroidal anti-inflammatory drugs-gastropathy and other diseases during long-term treatment with PPIs. Understanding the pathophysiological and morphological mechanisms of compensation and adaptation, the mechanisms of sanogenesis and carcinogenesis will increase the number of indications for long-term use of PPIs with a high level of efficiency and safety of treatment. In addition, understanding the pathophysiological and morphological mechanisms of compensation and adaptation, the mechanisms of sanogenesis will allow us to forecast the side effects of long-term use of potassium-competitive acid blockers.

Impact of Helicobacter pylori infection on neoadjuvant chemotherapy in locally advanced gastric cancer: a retrospective analysis

BACKGROUND

Helicobacter pylori (H. pylori) infection may affect the efficacy of immunotherapy and adjuvant chemotherapy in gastric cancer patients. However, the role of H. pylori infection in neoadjuvant chemotherapy in patients with locally advanced gastric cancer (LAGC) remains unclear. This study investigated the effect of H. pylori infection on neoadjuvant chemotherapy and prognosis of patients with LAGC.

METHODS

This retrospective study utilized data from patients with LAGC who underwent neoadjuvant chemotherapy and surgical treatment at the Sixth Affiliated Hospital of Sun Yat-sen University from January 1, 2010, to January 31, 2021. Patients were grouped according to their H. pylori infection status. The responses of the two groups to neoadjuvant chemotherapy and oncological outcomes were then compared.

RESULTS

A total of 239 patients were included in the analysis, and the baseline characteristics of the H. pylori-positive (n = 51) and H. pylori-negative (n = 188) groups were comparable. Further analysis revealed that H. pylori infection was significantly associated with the major pathological response (P = 0.009). Multivariate analysis showed that factors related to major pathological response included; age ≤ 50 (OR: 0.423, 95% CI: 0.194-0.925), H. pylori infection (OR: 0.396, 95% CI: 0.183-0.854), pathological stage T 3/4 (OR: 0.524, 95% CI: 0.288-0.954), and CA12-5 > 35 U/mL (OR: 0.345, 95% CI: 0.132-0.904). Both overall survival (OS) and disease-free survival (DFS) rates were poorer in the H. pylori-positive group than in the H. pylori-negative group (OS: Log-Rank P = 0.035; DFS: Log-Rank P = 0.029).

CONCLUSION

This cohort study indicated that H. pylori infection may be associated with tumor response to neoadjuvant chemotherapy and survival outcomes in patients with LAGC.

Point-of-Care Diagnosis of Atrophic Gastritis by Serological Biomarker Test (GastroPanel® Quick Test) in Gastroscopy Referral Patients in India

Background: Increased demand of the serological biomarker test (GastroPanel®) in non-invasive diagnosis of gastric cancer (GC) risk conditions, i.e., atrophic gastritis (AG) and Helicobacter pylori (Hp) infection, prompted the design of GastroPanel® Quick test (GPQT) (Biohit Oyj, Helsinki, Finland) for point-of-care (POC) settings. Objective: This study validated the diagnostic accuracy (DA) of GPQT in diagnosis of AG and Hp among gastroscopy referral patients. Methods: Altogether, 266 patients were enrolled among the consecutive gastroscopy referrals at the Department of Gastroenterology, Fortis Hospital (Punjab, India). All patients underwent gastroscopy with biopsies (n = 249) classified using the Updated Sydney System (USS) and finger prick blood sampling for GPQT testing. Results: Biopsy-confirmed AG was found in 15.3% (38/249) of the patients. The overall agreement between the GPQT and the USS classification was 71.4% (95% CI 65.4-77.0%), with the weighted kappa (κw) of 0.823 (95% CI 0.773-0.862). In ROC analysis for moderate/severe AG of the corpus (AGC) endpoint, AUC = 0.990 (95% CI 0.979-1.000) and AUC = 0.971 (95% CI 0.948-0.995) for PGI and PGI/PGII, respectively. Hp IgG Ab test detected biopsy-confirmed Hp with AUC = 0.836 (95% CI 0.783-0.889). Conclusions: The GPQT favourably competes in accuracy with the ELISA test version (unified-GP) in diagnosis of AG and Hp in patients referred for diagnostic gastroscopy.

Prevalence of Helicobacter pylori infection in Chinese military personnel: A cross-sectional, multicenter-based study

BACKGROUND

Helicobacter pylori (H. pylori) infection is a prevalent disease encountered in military internal medicine and recognized as the main cause of dyspepsia, gastritis, and peptic ulcer, which are common diseases in military personnel. Current guidelines in China state all patients with evidence of active infection with H. pylori are offered treatment. However, the prevalence of H. pylori infection and its regional distribution in the military population remain unclear, which hinders effective prevention and treatment strategies. Understanding the prevalence of H. pylori infection in the military population will aid in the development of customized strategies to better manage this infectious disease.

AIM

To investigate the prevalence of H. pylori infection in the Chinese military population in different geographic areas.

METHODS

This multicenter, retrospective study included 22421 individuals from five tertiary hospitals located in north, east, southwest, and northwest cities of China. H. pylori infection was identified using the urea breath test, which had been performed between January 2020 and December 2021.

RESULTS

Of the 22421 military service members, 7416 (33.1%) were urea breath test-positive. The highest prevalence of H. pylori was in the 30-39 years age group for military personnel, with an infection rate of 34.9%. The majority of infected subjects were younger than 40-years-old, accounting for 70.4% of the infected population. The individuals serviced in Lanzhou and Chengdu showed a higher infection prevalence than those in Beijing, Nanjing, and Guangzhou, with prevalence rates of 44.3%, 37.9%, 29.0%, 31.1%, and 32.3%, respectively.

CONCLUSION

H. pylori infection remains a common infectious disease among military personnel in China and has a relatively high prevalence rate in northwest China.

Enhancement of host defense against Helicobacter pylori infection through modulation of the gastrointestinal microenvironment by Lactiplantibacillus plantarum Lp05

Objective

This study aimed to assess the impact of Lactiplantibacillus plantarum Lp05 (Lp05) on the gastrointestinal microbiome and pathophysiological status of mice infected with Helicobacter pylori (H. pylori), exploring its potential as a probiotic treatment for H. pylori infections.

Methods

In vitro, the interaction between Lp05 and H. pylori was analyzed using laser confocal and scanning electron microscopy. In vivo, C57BL/6 mice infected with H. pylori were treated with Lp05 and divided into six groups: control, model, quadruple therapy, and three dosage levels of Lp05 (2×107, 2×108, 2×109 CFU/mouse/day). Over six weeks, the impact of Lp05 on the gastrointestinal microbiome and physiological markers was assessed. Measurements included digestive enzymes (α-amylase, pepsin, cellulase), inflammatory markers (interleukin-17A, interleukin-23, interleukin-10, interferon-β, interferon-γ, FoxP3, endothelin, IP-10, TGF-β1), oxidative stress markers (catalase, malondialdehyde, superoxide dismutase, myeloperoxidase), and tissue pathology (via modified Warthin-Starry silver and H&E staining). Microbial community structure in the stomach and intestines was evaluated through 16S rRNA gene sequencing.

Results

In vitro studies showed Lp05 and H. pylori formed co-aggregates, with Lp05 potentially disrupting H. pylori cell structure, reducing its stomach colonization. In vivo, Lp05 significantly lowered gastric mucosal urease activity and serum H. pylori-IgG antibody levels in infected mice (p < 0.01). It also mitigated pathological changes in the stomach and duodenum, decreased inflammatory responses (ET, IL-17A, IL-23, TGF-beta1, and IP-10, p < 0.01 for all), and enhanced antioxidant enzyme activities (CAT and SOD, p < 0.01) while reducing MDA and MPO levels (p < 0.01), combating oxidative stress from H. pylori infection. Lp05 treatment significantly modified the intestinal and gastric microbiota, increasing beneficial bacteria like Lactobacillus and Ligilactobacillus, and decreasing harmful bacteria such as Olsenella, linked to pathological conditions.

Conclusion

Lp05 effectively modulates the gastrointestinal microbiome, reduces inflammation and oxidative stress, and suppresses H. pylori, promising for probiotic therapies with further research needed to refine its clinical use.

Eradication Therapy to Prevent Gastric Cancer in Helicobacterpylori-Positive Individuals: Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

BACKGROUND AND AIMS

Screening for, and treating, Helicobacter pylori in the general population or patients with early gastric neoplasia could reduce incidence of, and mortality from, gastric cancer. We updated a meta-analysis of randomized controlled trials (RCTs) examining this issue.

METHODS

We searched the literature through October 4, 2024, identifying studies examining effect of eradication therapy on incidence of gastric cancer in H pylori-positive adults without gastric neoplasia at baseline or H pylori-positive patients with gastric neoplasia undergoing endoscopic mucosal resection (EMR) in either RCTs or observational studies. The control arm received placebo or no eradication therapy in RCTs and no eradication therapy in observational studies. Follow-up was ≥2 years. We estimated relative risks (RR) of gastric cancer incidence and mortality.

RESULTS

Eleven RCTs and 13 observational studies were eligible. For RCTs, RR of gastric cancer was lower with eradication therapy in healthy H pylori-positive individuals (8 RCTs, 0.64; 95% confidence interval [CI], 0.48-0.84) and H pylori-positive patients with gastric neoplasia undergoing EMR (3 RCTs, 0.52; 95% CI, 0.38-0.71). RR of death from gastric cancer was lower with eradication therapy in healthy H pylori-positive individuals (5 RCTs, 0.78; 95% CI, 0.62-0.98). In observational studies, RR of future gastric cancer was lower with eradication therapy in H pylori-positive subjects without gastric neoplasia at baseline (11 studies, 0.56; 95% CI, 0.43-0.73) and H pylori-positive patients with gastric neoplasia undergoing EMR (2 studies, 0.19; 95% CI, 0.06-0.61).

CONCLUSIONS

This meta-analysis provides further evidence that administering eradication therapy prevents gastric cancer in H pylori-positive individuals, with consistency in results among studies of different design.

Therapeutic regimens against Helicobacter pylori infection without proton pump inhibitors in patients with corpus atrophic gastritis: a real-life single-centre longitudinal observational study

Background

Efficacy of eradication regimens in Helicobacter pylori (Hp) infection is commonly reported with proton pump inhibitors (PPIs). In patients with corpus atrophic gastritis, characterized by impaired acid secretion, PPI treatment is questionable.

Objectives

The current study aimed to assess in clinical practice the tolerability and eradication rate of modified eradication regimens without PPI as first-line treatment in patients with histologically Hp-positive corpus atrophic gastritis.

Design

Real-life longitudinal observational study.

Methods

Overall, 76 patients (77.6% females, age 58.5 (26-88) years) with histologically Hp-positive corpus atrophic gastritis were consecutively diagnosed (2001-2022). First-line eradication treatment was prescribed without PPIs: concomitant or sequential amoxicillin-based therapy (ABT) until 2016 (n = 30), then single-pill bismuth treatment (SPBT; n = 46). Treatment adherence and adverse events were clinically evaluated and treatment efficacy was assessed by histopathology (updated Sydney system) at 6 ± 3 months after treatment.

Results

Only mild adverse events not requiring medical treatment were observed in four patients treated with SPBT without PPIs (vomiting, self-limiting diarrhoea, nausea, abdominal discomfort) and in two treated with ABT without PPIs (vomiting and abdominal discomfort). Overall, 71/76 (93.4%) corpus atrophic gastritis patients completed the treatment: 43/46 (93.5%) SPBT without PPIs and 28/30 (93.3%) ABT without PPIs. Successful cure of Hp was observed in 64/71 patients: overall eradication rate 90.1%, 95%CI 69.4%-115.1%. 42/43 corpus atrophic gastritis patients treated with SPBT without PPIs were successfully cured against 22/28 of those treated with ABT without PPIs. The eradication rate was higher for SPBT than ABT: 97.7%, 95%CI 70.4%-132.0% vs 78.6%, 95%CI 49.2%-118.9%, p = 0.013.

Conclusion

In clinical practice, Hp cure can be achieved without PPIs as first-line treatment in about 90% of patients with corpus atrophic gastritis.

Safety and effectiveness of dual therapy for Helicobacter pylori infection and the effect on the glycated hemoglobin level in type 2 diabetes

Patients with diabetes have a high risk of failure of H. pylori eradication therapy. The present study aims to evaluate the efficacy and safety of vonoprazan-amoxicillin (VA) dual therapy for the treatment of H. pylori infection in patients with type-2 diabetes mellitus (T2DM), and determine the influence of H. pylori eradication on the glycated hemoglobin A1C (A1C) level. The present prospective, single-center, single-arm, clinical trial enrolled 75 T2DM patients diagnosed with H. pylori infection. The patients were treated with the VA dual therapy regimen, which comprised of vonoprazan (20 mg, twice daily) and amoxicillin (750 mg, thrice daily), for 14 days (14-day VA dual therapy). The eradication rate in the intention-to-treat analysis and per-protocol analysis was 84.00% (63/75) and 87.14% (61/70), respectively. The multivariate analysis revealed that the independent risk factors for H. pylori eradication failure were smoking (OR: 4.59, 95% CI: 1.20-17.58, p = 0.026) and elevated A1C level (OR: 1.65, 95% CI: 1.01-2.68, p = 0.044). Patients in the successful eradication group presented with a significant decrease in the A1C level at 3 months, post-treatment, when compared to the pre-eradication level (7.70 ± 1.05% vs. 7.23 ± 1.00%, p = 0.006). VA dual therapy is a safe and effective regimen for patients with T2DM.

Helicobacter pylori infection promotes M1 macrophage polarization and gastric inflammation by activation of NLRP3 inflammasome via TNF/TNFR1 axis

BACKGROUND

Macrophages play a crucial role in chronic gastritis induced by the pathogenic Helicobacter pylori (H. pylori) infection. NLRP3 inflammasome has emerged as an important component of inflammatory processes. However, the molecular mechanism by which H. pylori infection drives NLRP3 inflammasome and macrophages activation remains unclear.

METHODS

Human gastritis tissues were collected for clinical significance of NLRP3. Infection with H. pylori was performed using in vitro and in vivo models. Bone marrow-derived macrophages (BMDMs) from wild-type (WT), Nlrp3-knockout (KO) and Tnfr1-KO mice were infected with H. pylori. Western blotting, qRT-PCR, immunofluorescence, immunohistochemistry and ELISA were utilized for functional and mechanistic studies.

RESULTS

Single-cell RNA sequencing (ScRNA-seq) analysis of human gastric tissues, followed by validation, indicated that NLRP3 was primarily expressed in myeloid cells and was significantly increased in H. pylori-positive gastritis compared to H. pylori-negative gastritis. Infection with PMSS1 and NCTC11637 H. pylori strains induced NLRP3 inflammasome activation in vitro (THP1 cells) and in the insulin-gastrin (INS-GAS) transgenic mouse model. Deletion of NLRP3 in BMDMs showed marked inhibition of H. pylori-induced M1 macrophage polarization. Furthermore, NLRP3 inflammasome activation upon TNFα, or H. pylori stimulation, was partially blocked by TNFα/TNFR1 signaling inhibitors. Deletion of TNFR1 in BMDMs significantly impaired NLRP3 inflammasome activation and M1 macrophages induced by H. pylori.

CONCLUSION

This study revealed that the activation of NLRP3 inflammasome, regulated by the TNF/TNFR1 signaling axis, is a key regulator of H. pylori-induced M1 macrophage activation and gastritis.

Gastric Microbiota Associated with Gastric Precancerous Lesions in Helicobacter pylori-Negative Patients

Studies on the gastric microbiota associated with gastric precancerous lesions remain limited. This study aimed to profile the gastric mucosal microbiota in patients with Helicobacter pylori-negative precancerous lesions. Gastric mucosal samples were obtained from 67 H. pylori-negative patients, including those with chronic gastritis (CG), intestinal metaplasia (IM), and dysplasia. The V3-V4 region of the 16S rRNA gene was sequenced and analyzed. No significant difference was observed in the alpha or beta diversity of the gastric microbiota among the groups. However, a taxonomic analysis revealed a significant enrichment of Lautropia mirabilis and the depletion of Limosilactobacillus reuteri, Solobacxterium moorei, Haemophilus haemolyticus, and Duncaniella dubosii in the IM and dysplasia groups compared to those in the CG group. Prevotella jejuni and the genus Parvimonas were enriched in the IM group. A predictive functional analysis revealed enrichment of the ornithine degradation pathway in the IM and dysplasia groups, suggesting its role in persistent gastric mucosal inflammation associated with gastric precancerous lesions. The gastric microbiota associated with H. pylori-negative gastric precancerous lesions showed an increased abundance of oral microbes linked to gastric cancer and a reduction in anti-inflammatory bacteria. These alterations might contribute to chronic gastric mucosal inflammation, promoting carcinogenesis in the absence of H. pylori infection.

Should Metronidazole Be Included in Second-Line Treatment After Standard Triple Therapy for Helicobacter pylori?: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND AIM

Although standard triple therapy remains the first-line eradication treatment for H. pylori worldwide, it is unclear whether metronidazole should be included empirically in second-line eradication treatments. The aim of this study was to compare the efficacy of metronidazole-containing regimens with that of metronidazole-free regimens after failure of first-line eradication using standard triple therapy.

METHODS

PubMed, the Cochrane Library, and the Igaku-Chuo-Zasshi database were searched to identify RCTs eligible for inclusion in this systematic review and meta-analysis. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated.

RESULTS

Thirteen eligible RCTs were included, with a total of 2039 patients assigned to metronidazole-containing (975 patients) or metronidazole-free (1064 patients) regimens. Metronidazole-containing regimens had significantly lower eradication failure rates than regimens without metronidazole (OR 0.55; 95% CI, 0.39-0.78). Subgroup analysis based on the regional risk of metronidazole resistance demonstrated that metronidazole-containing regimens had lower eradication failure rates not only in low-risk regions but also in high-risk regions (OR, 0.29; 95% CI, 0.11-0.74 and OR, 0.66; 95% CI, 0.49-0.91, respectively).

CONCLUSION

After failure of standard triple therapy, secondary eradication treatment regimens containing metronidazole demonstrate higher eradication rates than those without metronidazole.

Ethnic Inequity in the Current Approach to H. pylori Testing and Treatment: Linked Data Cohort Analysis

BACKGROUND

As seen globally, there are up to sixfold differences in gastric cancer mortality by ethnicity in Aotearoa New Zealand, and H. pylori is the major modifiable risk factor. This study investigates whether current H. pylori testing and treatment approaches are equitable.

MATERIALS AND METHODS

The study design was a retrospective cohort analysis of linked administrative health data. Laboratory testing data and pharmacy dispensing were linked to the Northern region health user population dataset (1.9 million) from 2015 to 2018. We investigated an individual's first test for H. pylori. Regression analyses compared ethnic differences in rates of H. pylori testing, infection, treatment, and retesting, adjusted for age, sex, and calendar year.

RESULTS

Ethnic inequities were present across the clinical pathway. Compared to sole-European, testing rates were lowest in Māori (OR 0.69) and Pacific (OR 0.81) and highest in Middle-Eastern/Latin-American/African (MELAA) (OR 2.21) and Asian (OR 2.02). Positivity rates were highest in MELAA (RR 2.96, 39%) and Pacific (RR 2.84, 38%) followed by Asian (RR 1.93, 26%) and Māori (RR 1.71, 23%). Treatment rates were similar for Asian (HR 1.05), MELAA (HR 1.03), and Māori (HR 0.98) compared to sole-European but lower in Pacific (HR 0.90). Māori and Pacific were half as likely to be retested as sole-European.

CONCLUSIONS

Despite the higher prevalence of H. pylori and gastric cancer, Māori and Pacific are relatively underserved with lower rates of testing and treatment than sole-European. Improved guidelines and the consistent application of these along with an equity-focused test and treat program are likely to be particularly beneficial for Māori and Pacific in addressing inequities.

Prognostic impact of subepithelial Helicobacter pylori infection on clinical outcomes in patients with dyspepsia

Several in vivo and in vitro studies have shown that Helicobacter pylori can invade epithelial cells and the lamina propria, potentially leading to underdiagnosis due to its subepithelial location. This retrospective study investigated H. pylori infection patterns and their impact on clinical improvement. Gastric tissue biopsies from 346 patients (August to December 2021) were studied using four commercially available immunohistochemical antibodies (TMDU, BioGenex, Cell Marque, and DAKO). The bacteria were graded based on their surface epithelial and subepithelial locations and then combined to establish an overall pattern. BioGenex, the antibody with the highest diagnostic performance due to its superior detection of surface and subepithelial cases, was selected as the gold standard for determining study outcomes. The isolated subepithelial H. pylori pattern was found to be an independent unfavorable prognostic feature. Patients with this pattern had the worst clinical outcomes compared to groups with isolated surface epithelial or other mixed patterns, which did not significantly differ. Subepithelial H. pylori should be included in pathological reports alongside the updated Sydney System. Further research should explore whether its eradication could improve treatment outcomes.

Comparative efficacy of Helicobacter pylori eradication therapy between tegoprazan-based concomitant and bismuth quadruple therapies: A real-world evidence

BACKGROUND AND AIM

Tegoprazan, a potassium-competitive acid blocker, can be used as a substitute for proton pump inhibitors in Helicobacter pylori eradication therapy; some studies have reported improved efficacy. In Korea, where clarithromycin resistance rates are high, we aimed to compare the efficacies of tegoprazan-based concomitant and bismuth quadruple therapies.

METHODS

We retrospectively analyzed data from patients with H. pylori infection who received either 10-day tegoprazan-based concomitant therapy or 14-day tegoprazan-based bismuth quadruple therapy as first-line treatment. The primary outcome was H. pylori eradication rate, with secondary outcomes including adverse events and insufficient medication rates.

RESULTS

Among the 1082 patients included in the study, 620 and 462 were treated with tegoprazan-based concomitant and bismuth quadruple therapies, respectively. Intention-to-treat analysis demonstrated no difference in eradication rates between the tegoprazan-based concomitant and bismuth quadruple therapy groups (74.7% [95% confidence interval-CI, 71.1-78.0%] vs 74.7% [95% CI, 70.6-78.5%], P = 0.999). Per-protocol analysis also showed similar eradication rates between the two groups (88.0% [95% CI, 85.0-90.6%] vs 89.7% [95% CI, 86.3-92.5%], P = 0.424). The overall adverse event rates (49.6% vs 39.2%, P = 0.001) and insufficient medication rates (4.8% vs 2.4%, P = 0.036) were higher in the bismuth quadruple therapy group than in the concomitant therapy group.

CONCLUSIONS

The eradication rates of tegoprazan-based 10-day concomitant therapy and 14-day bismuth quadruple therapy were comparable. However, because of its shorter treatment duration, better medical adherence, and lower incidence of adverse events, tegoprazan-based concomitant therapy may be preferable in regions with high rates of clarithromycin and metronidazole resistance.

Factors associated with Helicobacter pylori antimicrobial resistance in a US pediatric cohort

OBJECTIVES

The rising rates of Helicobacter pylori antimicrobial resistance highlight the importance of better understanding its epidemiology in the pediatric population. We aim to study the epidemiological factors associated with antimicrobial resistance in a cohort of US children with H. pylori infection.

METHODS

A retrospective cohort study of patients in the New England region of the United States between January 15, 2015 and October 15, 2022, with a first-time diagnosis of H. pylori on gastric biopsy and who had antimicrobial resistance data available. Descriptive statistics and logistic regression models were used to determine associations between the patient's demographics, clinical factors, endoscopic findings, and antimicrobial resistance.

RESULTS

Out of 273 patients (46% male, median 12.8 years), 118 (43.2%) were resistant to at least one antimicrobial. Clarithromycin resistance (24.5%) was the highest, followed by metronidazole (21.6%), fluoroquinolones (9.9%), rifabutin (3.3%), and amoxicillin (2.6%). Clarithromycin resistance was higher in Asians compared to White individuals (odds ratio [OR]: 4.68, 95% confidence interval [CI]: [2.01-10.89], p < 0.001), and lower in Black compared to White individuals (OR: 0.23, 95% CI: [0.08-0.69], p = 0.01). Antimicrobial resistance to clarithromycin and metronidazole were similar among Hispanics. Asian individuals were more likely to demonstrate one or more antimicrobial resistances compared to White (OR: 3.66, 95% CI: [1.50-8.89], p < 0.001). Compared to individuals from higher household incomes (>$100,000), those from less than $30,000 household incomes had a higher risk of metronidazole resistance (OR: 7.94, 95% CI: [1.83-34.36], p = 0.01).

CONCLUSION

Our study provides novel information concerning the association of H. pylori antimicrobial resistance to race, socioeconomic status, and age in the pediatric population.

Active Helicobacter pylori Infection Does Not Influence Outcomes After Sleeve Gastrectomy-Observational Cohort Study

Background: Helicobacter pylori (HP) is under investigation for its potential role in postoperative complications. While some studies indicate no impact, they often cite short or incomplete follow-up. This study aims to compare 1-year outcomes in groups with and without active HP infection after bariatric surgery, also assessing HP prevalence in postoperative specimens of sleeve gastrectomy (SG) patients. Methods: Conducted between May 2020 and May 2021, this study involves both retrospective and prospective data collection from 93 eligible SG patients. Demographics, surgical outcomes and follow-up results (including complications; weight and BMI at 3, 6 and 12 months post-SG) were extracted. Results: No statistically significant differences in body weight were observed at 3 (p = 0.3757), 6 (p = 0.1422) or 12 (p = 0.2737) months post-surgery between the HP-positive (Group A) and non-infected (Group B) groups. Group A experienced significant reductions in body weight at 6 and 12 months (p < 0.0001), while group B showed significant reductions at 3, 6 and 12 months (p < 0.0001), with additional decreases at 6 and 12 months post-surgery compared to 3 months. No significant differences in overall surgery-related side effects were observed between the groups. Conclusions: Patients with active HP infections undergoing SG displayed comparable rates of short- and long-term complications to the non-infected group. Active HP infection did not impact body weight loss outcomes at 12 months, but it may potentially slow it down in the initial three-month post-surgery period. This underscores the need to consider eradication while maintaining awareness of the potential side effects associated with the process.

Ten-day vonoprazan-amoxicillin dual therapy versus 14-day esomeprazole-amoxicillin dual therapy for first-line Helicobacter pylori eradication: a prospective multicenter randomized controlled trial

Background

The efficacy of the 14-day esomeprazole-amoxicillin (EA) dual therapy in eradicating Helicobacter pylori (H. pylori) has been widely discussed previously. Vonoprazan, a novel potassium-competitive acid blocker, presents rapid, potent, and long-lasting acid inhibitory effects compared to esomeprazole. However, there is currently a scarcity of direct comparisons between the 10-day vonoprazan-amoxicillin (VA) and the 14-day EA dual therapy for H. pylori eradication.

Objectives

This study aimed to compare the efficacy and safety of the 10-day VA and the 14-day EA dual therapy for H. pylori first-line eradication.

Design

This study was a prospective, multicenter, open-label, randomized controlled trial.

Methods

The study was conducted at 10 hospitals in China. In total, 570 newly diagnosed H. pylori-infected patients were recruited from April 2023 to February 2024. These patients were randomly assigned to either the 10-day VA group (vonoprazan 20 mg twice daily + amoxicillin 1000 mg three times daily) or the 14-day EA group (esomeprazole 20 mg four times daily + amoxicillin 750 mg four times daily). The primary outcome was the eradication rate, with secondary outcomes including adverse events and compliance.

Results

The 10-day VA regimen outperformed the 14-day EA regimen in terms of eradication rates in intention-to-treat (ITT) analysis (85.4% vs 76.7%, p = 0.008), modified ITT analysis (90.7% vs 84.8%, p = 0.036), and per-protocol (PP) analysis (91.1% versus 85.5%, p = 0.047). The non-inferiority p-values in all three analyses were less than 0.001. No statistically significant difference was observed in the incidence of adverse events between the two groups (9.1% vs 11.7%, p = 0.308). The 10-day VA regimen demonstrated higher compliance compared to the 14-day EA regimen (p = 0.006).

Conclusion

The 10-day VA dual therapy showed a satisfactory eradication rate of 91.1% (PP analysis), demonstrating good safety and better compliance compared to the 14-day EA dual therapy as the first-line eradication.

Trial registration

This trial was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR2300070475) on April 12, 2023.

Global prevalence of Helicobacter pylori antibiotic resistance among children in the world health organization regions between 2000 and 2023: a systematic review and meta-analysis

BACKGROUND

Helicobacter pylori infection causes gastritis, peptic ulcers, and gastric cancer. The infection is typically acquired in childhood and persists throughout life. The major impediment to successful therapy is antibiotic resistance. This systematic review and meta-analysis aimed to comprehensively assess the global prevalence of antibiotic resistance in pediatric H. pylori infection.

METHODS

We performed a systematic search of publication databases that assessed H. pylori resistance rates to clarithromycin, metronidazole, levofloxacin, amoxicillin, and tetracycline in children. The WHO region classification was used to group pooled primary and secondary resistance estimates along with 95% confidence interval (CI). H. pylori antibiotic resistance rates were retrieved and combined with odds ratios (95% CI) to investigate the global prevalence and temporal trends. Subgroup analysis of the prevalence of antibiotic resistance was conducted by country, age groups, and susceptibility testing methods.

RESULTS

Among 1417 records obtained initially, 152 studies were selected for eligibility assessment after applying exclusion criteria in multiple steps. Ultimately, 63 studies involving 15,953 individuals were included comprising data from 28 countries in 5 WHO regions. The primary resistance rates were metronidazole 35.3% (5482/15,529, 95% CI: 28.7-42.6), clarithromycin 32.6% (5071/15,555, 95% CI: 27.7-37.9), tetracycline 2.1% (148/7033, 95% CI: 1.3-3.6), levofloxacin 13.2% (1091/8271, 95% CI: 9.3-18.4), and amoxicillin 4.8% (495/10305, 95% CI: 2.5-8.8). Raising antibiotic resistance was detected in most WHO regions.

CONCLUSIONS

The escalating trend of H. pylori antibiotic resistance in children warrants urgent attention globally. National and regional surveillance networks are required for antibiotic stewardship in children infected with H. pylori.

Efficacy of susceptibility-guided quadruple therapy with antibiotic resistance using the string test coupled with quantitative PCR for Helicobacter pylori eradication: a protocol of a multicentre, open, randomised clinical trial

INTRODUCTION

Helicobacter pylori is a major health problem, with the high prevalence of H. pylori and the increasing antibiotic resistance rate in China. Antibiotic resistance is the main reason for the failure of H. pylori eradication. This study aims to evaluate the efficacy and safety of susceptibility-guided quadruple therapy with antibiotic resistance using the string test coupled with quantitative PCR (qPCR) for H. pylori eradication.

METHODS AND ANALYSIS

This is a multicentre, open, randomised clinical trial that will enroll 324 patients with H. pylori infection. Patients will be randomised to two groups for a 14-day treatment: Treatment group will be treated with proton pump inhibitor (PPI), bismuth with two different kinds of antibiotics susceptibly guided by string test coupled with qPCR, while control group will be treated empirically with PPI, bismuth with two different kinds of antibiotics. The types and dosages of bismuth, PPI and antibiotics administered in this trial are based on the 2022 Chinese Guidelines for the treatment of H. pylori infection and the Sixth Chinese National Consensus Report on the management of H. pylori infection. The primary endpoint is the eradication rate, while secondary endpoints include compliance, the incidence of adverse events and adverse drug reactions.

ETHICS AND DISSEMINATION

This study was approved by the ethics committee of the Third People's Hospital of Zhengzhou (No. 2024-04-001-K02). The results will be published in the appropriate peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ChiCTR2400082768.

Helicobacter pylori resistance in Hainan Province, China: investigating phenotypes and genotypes through whole-genome sequencing

Helicobacter pylori is increasingly resistant to antibiotics, significantly lowering eradication rates and posing a major public health challenge. This study investigated the distribution of antibiotic-resistant phenotypes and genotypes of H. pylori in Hainan Province. It determined the minimum inhibitory concentrations (MICs) of six antibiotics using the E-test method and detected resistance genes via Sanger sequencing. Furthermore, we compared resistance detection based on phenotypic analysis and whole genome sequencing (WGS) across 19 clinical isolates of H. pylori. A total of 140 H. pylori strains were isolated. The resistance rates to levofloxacin (LEV), clarithromycin (CLA), and metronidazole (MTZ) were 37.9%, 40.0%, and 93.6%, respectively. Notably, only 3.3% of the strains were susceptible to all six antibiotics. Multidrug-resistant strains accounted for 25.0% of the total, with no resistance detected to amoxicillin (AMX), tetracycline (TET), or furazolidone (FR) during the study period. Genotypic resistance to CLA and LEV showed near-perfect concordance with phenotypic resistance, with Kappa values of 0.910 and 0.938, respectively. Although all isolates were phenotypically sensitive to TET, 16 exhibited a mutation in the 16S rRNA gene (A926G). All strains harboring the R16H/C mutation and truncated rdxA were resistant to metronidazole, demonstrating a specificity of 100%. Therefore, FR, AMX, and TET are recommended as suitable empirical treatment options for H. pylori infections in this region. Genotypic analysis provides a reliable method for predicting resistance to CLA and LEV. WGS proves to be a valuable tool for identifying novel resistance loci in H. pylori and contributes to the phylogenetic classification of strains.

Smoking-attributable peptic ulcer disease mortality worldwide: trends from 1990 to 2021 and projections to 2046 based on the global burden of disease study

Objective

Smoking is a major risk factor for peptic ulcer disease (PUD) mortality. This study aims to analyze global trends in smoking-attributable PUD mortality from 1990 to 2021 and project future trends to 2046.

Methods

Data were obtained from the Global Burden of Disease Study 2021. We calculated age-standardized mortality rates (ASMR) and estimated annual percentage changes (EAPC) for smoking-attributable PUD mortality. Bayesian Age-Period-Cohort models were used to project future trends.

Results

From 1990 to 2021, global smoking-attributable PUD deaths decreased from 48,900 to 29,400, with the ASMR declining from 1.2 to 0.3 per 100,000 (EAPC: -4.25%). High-income regions showed faster declines, while some low- and middle-income countries experienced slower progress or even increases. Projections suggest a continued global decline in smoking-attributable PUD mortality to 2046, with persistent regional disparities. By 2046, the global ASMR is expected to decrease to approximately 0.1 per 100,000, with higher rates persisting in certain regions such as the Solomon Islands (3.7 per 100,000) and Cambodia (1.6 per 100,000).

Conclusion

While global smoking-attributable PUD mortality has significantly decreased and is projected to continue declining, substantial regional disparities persist. These findings underscore the need for targeted tobacco control interventions, particularly in high-risk regions, to further reduce the global burden of smoking-attributable PUD mortality.

Experience of Metronidazole Triple Therapy After Clarithromycin Triple Therapy Failure for Helicobacter pylori Eradication in Korea

Background/Objectives: Bismuth quadruple therapy (BQT) is recommended as the best second-line regimen after failure of first-line clarithromycin triple therapy (CTT) for Helicobacter pylori eradication. However, there are some limitations to this approach, including the lack of an appropriate sequel regimen after failure of BQT and complicated administration. Metronidazole triple therapy (MTT) is simple to administer, but it is not widely recommended. This study was conducted to determine the efficacy of MTT as second-line regimen for H. pylori eradication after failure of CTT. Methods: We retrospectively reviewed the medical records of the Korean patients with H. pylori infection who underwent second-line treatment after failure of first-line CTT from October 2013 to October 2019. The efficacy of MTT and BQT for H. pylori eradication was compared. Results: The eradication rate in the BQT group tended to be higher than that in the MTT group; however, the difference was not statistically significant (208/233, 89.3% versus 244/284, 85.9%, p = 0.287). Among 40 patients with second-line MTT eradication failure, 21 received the third-line BQT, and 15 showed successful eradication (15/21, 71.4%). In the men 70 years or older, the eradication rate of MTT was lower than that of BQT without statistical significance (75.8% versus 94.1%, p = 0.141). Conclusions: These findings suggested that MTT could be a second-line treatment option, reserving BQT for Helicobacter pylori eradication after first line CTT failure, except in elderly men 70 years or older.

Role of high-dose amoxicillin dual therapy for Helicobacter pylori eradication in an Irish cohort: A prospective study

Helicobacter pylori (H. pylori) infections may cause chronic gastritis, peptic ulcer disease, gastric cancers, and other conditions outside of the gastrointestinal tract. Hence, it is important to diagnose and treat it early. H. pylori is resistant to certain drugs in traditional eradication therapy, so alternative therapy protocols are needed, such as high-dose amoxicillin dual therapy (HDADT). This article aims to comment on a recent paper by Costigan et al in the World Journal of Clinical Cases. In this study, the authors recruited 139 patients diagnosed with H. pylori, all treated with HDADT. Of these, 93 were treatment-naïve and 46 had received at least one alternative treatment in the past. Four weeks after the end of the treatment, the urea breath test was administered to estimate the eradication rate. The total eradication rate was 56% (78/139), 62% for the treatment-naïve arm and 43% for the previous treatment arm, thus indicating a lower success rate for the arm that had previously received a different treatment regimen. In conclusion, a therapeutic approach with first-line HDADT may potentially be a better treatment, but the results are not sufficient to recommend the use of this regimen in a country with high levels of dual resistance.

Evolution of the use, effectiveness and safety of bismuth-containing quadruple therapy for Helicobacter pylori infection between 2013 and 2021: results from the European registry on H. pylori management (Hp-EuReg)

BACKGROUND

Bismuth quadruple therapies (BQTs) including bismuth, a proton pump inhibitor (PPI) and two antibiotics have been shown to be highly effective for treating Helicobacter pylori infection even in areas of high bacterial antibiotic resistance.

OBJECTIVE

To describe the time trends of use, effectiveness and safety of BQT in Europe using the European Registry on Helicobacter pylori Management (Hp-EuReg).

DESIGN

Patients registered in the Hp-EuReg from 2013 to 2021 who had received BQT were included. The regimens prescribed, the number of eradication attempts, effectiveness, adherence and safety were analysed. The effectiveness was assessed by modified intention to treat (mITT). Time-trend and multivariate analyses were performed to determine variables that predicted treatment success.

RESULTS

Of the 49 690 patients included in the Hp-EuReg, 15 582 (31%) had received BQT. BQT use increased from 8.6% of all treatments in 2013 to 39% in 2021. Single-capsule BQT-containing bismuth, metronidazole and tetracycline-plus a PPI (single-capsule BQT, ScBQT) was the most frequent treatment mode (43%). Schemes that obtained an effectiveness above 90% were the 10-day ScBQT and 14-day BQT using tetracycline plus metronidazole, or amoxicillin plus either clarithromycin or metronidazole. Only ScBQT achieved above 90% cure rates in all the geographical areas studied. Using the ScBQT scheme, adherence, the use of standard or high-dose PPIs, 14-day prescriptions and the use of BQT as first-line treatment were significantly associated with higher mITT effectiveness.

CONCLUSION

The use of BQT increased notably in Europe over the study period. A 10-day ScBQT was the scheme that most consistently achieved optimal effectiveness.

TRIAL REGISTRATION NUMBER

NCT02328131.

Functional Dyspepsia and Gastroesophageal Reflux Disease: From Pathogenesis to Current Treatment Strategies

Aim: to present a modern view on the combination of functional dyspepsia (FD) and gastroesophageal reflux disease (GERD) and to evaluate the effectiveness of acotiamide in patients with FD and GERD.

Key points. The high frequency of the combination of FD and GERD is caused by common pathogenetic mechanisms and presents an urgent problem in clinical practice. The concurrent occurrence of these diseases alters the clinical picture, complicates differential diagnostics, and leads to inadequate prescription of drugs. Medical treatment for patients with FD and GERD includes the use of proton pump inhibitors (PPIs) and prokinetics. Currently, acotiamide is recognized as an effective drug that affects the motility of the upper gastrointestinal tract. Acotiamide is an antagonist of muscarinic M1 and M2 receptors and a reversible inhibitor of acetylcholinesterase. The clinical efficacy of this drug has been demonstrated not only in patients with FD but also in those with a combination of FD and GERD.

Conclusion. Administration of acotiamide is pathogenetically justified in patients with the combination of GERD and FD.

Helicobacter pylori: Routes of Infection, Antimicrobial Resistance, and Alternative Therapies as a Means to Develop Infection Control

Helicobacter pylori (H. pylori) is a Gram-negative, spiral-shaped bacterium that colonizes the gastric epithelium and is associated with a range of gastrointestinal disorders, exhibiting a global prevalence of approximately 50%. Despite the availability of treatment options, H. pylori frequently reemerges and demonstrates increasing antibiotic resistance, which diminishes the efficacy of conventional therapies. Consequently, it is imperative to explore non-antibiotic treatment alternatives to mitigate the inappropriate use of antibiotics. This review examines H. pylori infection, encompassing transmission pathways, treatment modalities, antibiotic resistance, and eradication strategies. Additionally, it discusses alternative therapeutic approaches such as probiotics, anti-biofilm agents, phytotherapy, phototherapy, phage therapy, lactoferrin therapy, and vaccine development. These strategies aim to reduce antimicrobial resistance and enhance treatment outcomes for H. pylori infections. While alternative therapies can maintain low bacterial levels, they do not achieve complete eradication of H. pylori. These therapies are designed to bolster the immune response, minimize side effects, and provide gastroprotective benefits, rendering them suitable for adjunctive use alongside conventional treatments. Probiotics may serve as adjunctive therapy for H. pylori; however, their effectiveness as a monotherapy is limited. Photodynamic and phage therapies exhibit potential in targeting H. pylori infections, including those caused by drug-resistant strains, without the use of antibiotics. The development of a reliable vaccine is also critical for the eradication of H. pylori. This review identifies candidate antigens such as VacA, CagA, and HspA, along with various vaccine formulations, including vector-based and subunit vaccines. Some vaccines have demonstrated efficacy in clinical trials, while others have shown robust immune protection in preclinical studies. Nevertheless, each of the aforementioned alternative therapies requires thorough preclinical and clinical evaluation to ascertain their efficacy, side effects, cost-effectiveness, and patient compliance.

Peptic Ulcer Disease: A Review

Importance

In the US, peptic ulcer disease affects 1% of the population and approximately 54 000 patients are admitted to the hospital annually for bleeding peptic ulcers.

Observations

Approximately 10% of patients presenting with upper abdominal pain in a primary care setting have a peptic ulcer as the cause of their symptoms. The principal causes of peptic ulcer disease are Helicobacter pylori infection, which affects approximately 42% of patients with peptic ulcer disease, and aspirin or nonsteroidal anti-inflammatory drug (NSAID) use, which are etiologic factors in approximately 36% of people with peptic ulcer disease. Complications of peptic ulcer include bleeding (73% of patients), perforation (9% of patients), and pyloric obstruction (3% of patients). Annually, 10 000 people die of peptic ulcer disease in the US. Endoscopy definitively diagnoses peptic ulcer disease. Acid blockers, such as omeprazole, can heal peptic ulcers in approximately 80% to 100% of patients within 4 weeks, but gastric ulcers larger than 2 cm may require 8 weeks of treatment. Eradication of H pylori decreases peptic ulcer recurrence rates from approximately 50% to 60% to 0% to 2%. Discontinuing NSAIDs heals 95% of ulcers identified on endoscopy and reduces recurrence from 40% to 9%. When discontinuing an NSAID is not desirable, changing the NSAID (eg, from ketorolac to ibuprofen), adding a proton pump inhibitor such as omeprazole or lansoprazole, and eradicating H pylori with treatment such as bismuth, metronidazole, and tetracycline combined with omeprazole can reduce recurrence rates.

Conclusions and Relevance

Peptic ulcer disease is associated with increased hospitalization rates and mortality. Acid blocking with proton pump inhibitors, such as omeprazole or lansoprazole, is the primary treatment. Recurrence of ulcers can be prevented by eradicating H pylori if present and discontinuing aspirin or NSAIDs if applicable.

Prevalence and Risk Factors of Helicobacter pylori Infection in Elderly Patients With Upper Gastrointestinal Symptoms in Vietnam

BACKGROUND AND AIM

Helicobacter pylori infection is a major cause of peptic ulcer disease and gastric cancer. Limited data exist on H. pylori prevalence and risk factors of infection among elderly individuals in Vietnam. This study aimed to determine the prevalence and associated risk factors of H. pylori infection in elderly Vietnamese patients with upper gastrointestinal symptoms.

METHODS

A cross-sectional study was conducted on patients aged ≥ 60 years with upper gastrointestinal symptoms who underwent endoscopy. The exclusion criteria included recent antibiotic or proton pump inhibitor use, prior H. pylori eradication, or upper gastrointestinal surgery. Data on demographics, hygiene, diet, and history were collected through structured questionnaires. H. pylori was diagnosed by a rapid urease test. Logistic regression was used to analyze risk factors.

RESULTS

Of 406 participants (mean age 65.4 ± 4.5 years, male-to-female ratio 1:2), H. pylori prevalence was 55.6%. The risk factors for H. pylori infection included infrequent tooth brushing (OR 18.14, 95% CI 3.94-83.55), overweight/obesity (OR 5.82, 95% CI 3.44-9.88), spicy food consumption (OR 5.18, 95% CI 2.74-9.79), a family history of upper gastrointestinal symptoms (OR 3.15, 95% CI 1.84-5.39), and cat ownership (OR 2.01, 95% CI 1.10-3.68). The vegetarian diet was protective (OR 0.04, 95% CI 0.01-0.18).

CONCLUSIONS

H. pylori prevalence in elderly Vietnamese is high, with risk factors including poor hygiene, obesity, spicy food, family history, and cat ownership. A vegetarian diet may be protective.

Vitamin B6 inhibits activity of Helicobacter pylori adenylosuccinate synthetase and growth of reference and clinical, antibiotic-resistant H. pylori strains

The current therapies against gastric pathogen Helicobacter pylori are ineffective in over 20% of patients. Enzymes belonging to the purine salvage pathway are considered as novel drug targets in this pathogen. Therefore, the main aim of the current study was to determine the antibacterial activity of pyridoxal 5'-phosphate (PLP), an active form of vitamin B6, against reference and clinical strains of H. pylori. Using a broad set of microbiological, physicochemical (UV absorption, LC-MS, X-ray analysis) and in silico experiments, we were able to prove that PLP inhibits adenylosuccinate synthetase (AdSS) from H. pylori by the competition with GTP (IC50eq ∼30 nM). This behaviour was attributed to formation of a Schiff base with a lysine residue (a covalent bond with Lys322 in the GTP binding site of AdSS) and was potentiated by the presence of vitamin C. This antibacterial activity of PLP gives hope for its future use against H. pylori.