A systematic review of Helicobacter pylori eradication therapy--the impact of antimicrobial resistance on eradication rates

Eradication Rate and Factors Influencing Helicobacter pylori Infection Clearance Using Standard Triple Therapy at a Single Centre in Jazan Region, Saudi Arabia: A Retrospective Study

Introduction

Helicobacter pylori infection is a common gastrointestinal infection that affects around 50% of the global population. This infection can lead to various health conditions such as peptic ulcer disease, dyspepsia, gastric carcinoma, and mucosa-associated lymphoid tissue lymphoma. The triple therapy which consists of proton-pump inhibitors, clarithromycin, and amoxicillin or metronidazole for 14 days is considered the first-line treatment for H. pylori and its eradication, especially in areas where clarithromycin sensitivity is still high. However, recent research shows that the efficacy of this treatment is decreasing due to antibiotic resistance.

Methods

This was a retrospective study that took place at Al-Hayat Jazan Hospital in Jazan, Saudi Arabia. The study analyzed the medical records of 186 patients with H. pylori who had undergone the standard triple therapy. The objectives of this study were to determine the eradication rate of H. pylori by using the standard triple therapy, and to highlight the influence of some demographic characteristics such as age, gender, diabetes mellitus, and smoking on the eradication rate, in Jazan region, Saudi Arabia.

Results

The medical records of 186 patients were included in the study. The overall rate of successful eradication was found to be 77.4%. The results of the study showed that the decline in the eradication rate was significantly associated with the presence of diabetes and smoking status (with p-values of <0.001 and <0.004, respectively).

Conclusion

This study finds that the standard triple therapy for H. pylori eradication is less effective than optimal standards, as per literature and guidelines. Given its declining efficacy globally, alternative first-line treatments may be necessary. Further research is needed to assess its effectiveness in various regional contexts.

Efficacy and tolerability of Helicobacter pylori eradication regimes in South Kivu, Eastern of the Democratic Republic of Congo: A single center observational study

Background and Aims

Treating Helicobacter pylori infections has become a major challenge due to increased antibiotic resistance. The aim of this study was to investigate the efficacy and tolerability of the main standard regimens recommended for H. pylori eradication in Bukavu, Eastern of the Democratic Republic of Congo.

Methods

The study enrolled patients with evidence of H. pylori infection in histological examination or serology testing combined with a positive fecal antigen test. As first-line treatment, patients were randomized to either a 10-days (OAC-10) or a 14-days (OAC-14) regimen, employing a combination of omeprazole 20 mg, amoxicillin 1 g, and clarithromycin 500 mg twice daily. In case of failure, a second line regimen was evaluated and included two others protocols: OAC-10 regimen + levofloxacin 500 mg (OAC-10+) and the bismuth-based therapy (pantoprazole + bismuth salt + metronidazole + tetracycline) during 10 days. Our primary endpoint was H. pylori eradication and secondarily, the compliance and adverse effects were also evaluated.

Results

A total of 179 patients were enrolled. The eradication rate was 79.2% and 80.5% with the OAC-10 and OAC-14 regimen, respectively (p = 0.796). Adverse effects were significant higher in the OAC-14 group than in the OAC-10 group (36.5% vs. 57.8%; p < 0.001). On the other hand, the compliance rate was slightly higher in the OAC-10 group (97.9% vs. 91.6%, p = 0.052) while clinical improvement was almost similar in both groups. Regarding the second line regimen, the bismuth-based therapy (n = 18) seemed to show a better response with 100% of eradication rate and 100% of clinical improvement.

Conclusion

The classic 10-days triple therapy seems to be as effective as the 14-days regimen while having in addition a good tolerance. Apart from cost issues, the bismuth-based therapy seems to be a very good alternative in case of first-line treatment failure.

Curcumin clarithromycin nano-form a promising agent to fight Helicobacter pylori infections

Helicobacter pylori (H. pylori) is the main cause of gastric diseases. However, the traditional antibiotic treatment of H. pylori is limited due to increased antibiotic resistance, low efficacy, and low drug concentration in the stomach. This study developed a Nano-emulsion system with ability to carry Curcumin and Clarithromycin to protect them against stomach acidity and increase their efficacy against H. pylori. We used oil in water emulsion system to prepare a novel Curcumin Clarithromycin Nano-Emulsion (Cur-CLR-NE). The nano-emulsion was validated by dynamic light scattering (DLS) technique, zeta potential; transmission electron microscopy (mean particle size 48 nm), UV-visible scanning and Fourier transform infrared spectroscopy (FT-IR). The in vitro assay of Cur-CLR-NE against H. pylori was evaluated by minimum inhibitory concentration (12.5 to 6.26 µg/mL), minimum bactericidal concentration (MBC) and anti-biofilm that showed a higher inhibitory effect of Cur-CLR-NE in compere with, free curcumin and clarithromycin against H. pylori. The in vivo results indicated that Cur-CLR-NE showed higher H. pylori clearance effect than free clarithromycin or curcumin under the same administration frequency and the same dose regimen. Histological analysis clearly showed that curcumin is highly effective in repairing damaged tissue. In addition, a potent synergistic effect was obvious between clarithromycin and curcumin in nano-emulsion system. The inflammation, superficial damage, the symptoms of gastritis including erosion in the mouse gastric mucosa, necrosis of the gastric epithelium gastric glands and interstitial oedema of tunica muscularis were observed in the positive control infected mice and absent from treated mice with Cur-CLR-NE.

Effects of CYP2C19 genetic polymorphisms on the cure rates of H. pylori in patients treated with the proton pump inhibitors: An updated meta-analysis

Background: The cure rates of Helicobacter pylori (H. pylori) treatment using a proton pump inhibitor (PPI) are gradually decreasing due to antibiotic resistance, poor compliance, high gastric acidity, and cytochrome P450 2C19 (CYP2C19) polymorphism, and the effects of PPI depend on metabolic enzymes, cytochrome P450 enzymes. The aim of this meta-analysis was to determine whether CYP2C19 polymorphisms affect H. pylori cure rates in patients treated with different proton pump inhibitors (PPIs) according to stratified analysis.

Materials and methods: The literature was searched with the key words “H. pylori” and “CYP2C19” in PubMed, CNKI, and Wanfang up to 31 May 2022, and the studies were limited to clinical observational or randomized controlled trials (RCTs). Finally, seven RCTs and 29 clinical observational studies met the inclusion criteria and were used for the meta-analysis via STATA version 16.

Results: The cure rates were significantly different between genotypes of homozygous extensive metabolizers (EM) and poor metabolizers (PM) (OR = 0.58, 95% CI: 0.47–0.71) and between EM and heterozygous extensive metabolizers (IM) (OR = 0.71, 95% CI: 0.59–0.86), but not between IM and PM. Moreover, there was a significantly lower H. pylori cure rate in EM subjects than that in IM subjects when treated with omeprazole (66.4% vs. 84.1%), lansoprazole (76.1% vs. 85.6%), but not rabeprazole, esomeprazole, or pantoprazole. In addition, there was a significantly lower H. pylori cure rate in EM subjects than that in IM subjects when treated with a PPIs for 7 days (77.4% vs. 82.1%), but not 14 days (85.4% vs. 90.0%).

Conclusion: Carriers of CYP2C19 loss-of-function variant alleles (IM and PM) exhibit a significantly greater cure rate of H. pylori than noncarriers (EM) regardless of other factors (84.7% vs. 79.2%). In addition, pantoprazole- and rabeprazole-based quadruple therapy for H. pylori treatment is less dependent on the CYP2C19 genotype and should be prioritized in Asian populations with H. pylori.

A randomized controlled trial to compare Helicobacter pylori eradication rates between the empirical concomitant therapy and tailored therapy based on 23S rRNA point mutations

BACKGROUND

Increasing clarithromycin resistance has led to changes in several guidelines for treatment of Helicobacter pylori infections. We compared the H. pylori eradication rates of the empirical concomitant therapy (CoT) and a tailored therapy (TaT) using dual-priming oligonucleotide-based polymerase chain reaction to detect mutations in the 23S rRNA gene that are related to clarithromycin resistance.

METHODS

Between June 2020 and May 2021, 290 patients were enrolled and randomly assigned to 2 groups. In the CoT group, the patients received rabeprazole 20 mg, amoxicillin 1 g, clarithromycin 500 mg, and metronidazole 500 mg twice daily for 14 days. In the TaT group, point mutation-negative patients received rabeprazole 20 mg, amoxicillin 1 g, and clarithromycin 500 mg twice daily for 14 days and point mutation-positive patients received rabeprazole 20 mg twice daily, metronidazole 500 mg thrice daily, and bismuth 120 mg and tetracycline 500 mg 4 times daily for 14 days.

RESULTS

A total of 290 and 261 patients were included in the intention-to-treat (ITT) and per-protocol (PP) analyses, respectively. A2142G and/or A2143G point mutations were identified in 28.6% of the patients. No significant difference in eradication rates were observed between the 2 groups as per ITT (CoT, 82.8% and TaT, 85.5%, P = .520) and PP (CoT, 88.6% and TaT, 94.6%, P = .084) analyses. In point mutation-positive patients, the eradication rates in the CoT group were lower than those in the TaT group as per ITT (69.8% and 87.5%, respectively, P = .050) and PP (76.9% and 97.1%, respectively, P = .011) analyses.

CONCLUSION

CoT and TaT showed similar overall eradication rates for H. pylori. However, CoT eradication rate was suboptimal, especially in point mutation-positive patients.

Tailored eradication strategy vs concomitant therapy for Helicobacter pylori eradication treatment in Korean patients

BACKGROUND

Antibiotic resistance to Helicobacter pylori (H. pylori) infection, which ultimately results in eradication failure, has been an emerging issue in the clinical field. Recently, to overcome this problem, an antibiotic sensitivity-based tailored therapy (TT) for H. pylori infection has received attention.

AIM

To investigate the efficacy and safety profiles of TT for H. pylori infection treatment compared to a non-bismuth quadruple therapy, concomitant therapy (CT) regimen.

METHODS

We included patients (> 18 years) with an H. pylori infection and without a history of Helicobacter eradication who visited the Gil Medical Center between March 2016 and October 2020. After being randomly assigned to either the TT or CT treatment group in 1 to 1 manner, patient compliance, eradication success rate (ESR), and patient-reported side effects profiles were assessed and compared between the two groups. H. pylori infection was diagnosed using a rapid urease test, Giemsa stain, or dual priming oligonucleotide polymerase chain reaction (DPO-PCR). Tailored eradication strategy based through the presence of a 23S ribosomal RNA point mutation. For the TT group, a DPO-PCR test, which detected A2142G and/or A2143G point mutations, and a clarithromycin resistance test were performed. Patients in the clarithromycin-resistant group were treated with a bismuth-containing quadruple combination therapy, while those with sensitive results were treated with the standard triple regimen.

RESULTS

Of the 217 patients with a treatment naive H. pylori infection, 110 patients [mean age: 58.66 ± 13.03, men, n = 55 (50%)] were treated with TT, and 107 patients [mean age: 56.67 ± 10.88, men, n = 52 (48.60%)] were treated with CT. The compliance (TT vs CT, 100% vs 98.13%, P = 0.30), and follow-up loss rates (8.18% vs 9.35%, P = 0.95) were not significantly different between the groups. The ESR after treatment was also not statistically different between the groups (TT vs CT, 82.73% vs 82.24%, P = 0.95). However, the treatment-related and patient-reported side effects were significantly lower in the TT group than in the CT group (22.77% vs 50.52%, P < 0.001).

CONCLUSION

The DPO-based TT regimen shows promising results in efficacy and safety profiles as a first-line Helicobacter eradication regimen in Korea, especially when physicians are confronted with increased antibiotic resistance rates.

Modified quadruple therapy or bismuth-containing quadruple therapy in the first-line treatment of Helicobacter pylori in Turkey

AIM

Helicobacter pylori (H. pylori) eradication is still an important issue in countries with high antibiotic resistance. This study aimed to compare the efficacy and safety of two bismuth-containing treatment modalities in H. pylori treatment in Turkey.

MATERIAL AND METHODS

subjects with H. pylori infection who were treated with either bismuth-containing quadruple therapy (pantoprazole 40 mg bid, tetracycline 500 mg qid, metronidazole 500 mg tid, bismuth subcitrate 262 mg qid daily) (BQT group) or modified quadruple therapy (pantoprazole 40 mg bid, amoxicillin 1 g bid, metronidazole 500 mg tid, bismuth subcitrate 262 mg qid daily) (MBQT group) for 14 days were compared, retrospectively. The eradication success rate, adverse events related to the medications and compliance were investigated.

RESULTS

a total of 128 patients in the BQT group and 102 patients in the MBQT group completed the treatment. The overall rate of adverse events was significantly higher in the BQT group compared with the MBQT group (39.4 % vs 18.6; p: 0.001). Among the adverse events, nausea-vomiting and abdominal discomfort was significantly more frequent in the BQT group than in the MBQT group (p: 0.001). The adverse events were mild-moderate in both groups and life threatening adverse events were not present in any of the patients.

CONCLUSION

although both regimens were highly effective and safe in H. pylori eradication, both intention-to-treat (ITT) and per-protocol (PP) eradication rates were higher and adverse events were lower in the modified quadruple therapy group. Modified quadruple therapy should be kept in mind for the first-line treatment of H. pylori in regions with high clarithromycin and metronidazole resistance.

The Effect of Helicobacter pylori Eradication on Gastric Wall Thickness in Patients Undergoing Laparoscopic Sleeve Gastrectomy

PURPOSE

The most important cause affecting the thickness of the gastric wall other than the tumor is chronic gastritis caused by Helicobacter pylori (Hp), which is most frequently detected in the antrum. This study aims to investigate the effect of bismuth-based treatment (BBT) combined with proton pump inhibitor (PPI) on wall thicknesses measured in the postoperative gastric specimen and early postoperative complications in patients with Hp-positive pre-LSG endoscopic gastric biopsies.

MATERIALS AND METHODS

The patients who underwent LSG procedure for morbid obesity were divided into three groups as follows: Hp-negative, Hp-positive without eradication treatment, and Hp-positive, and LSG was performed after eradication treatment. Macroscopic and microscopic gastric wall thickness measurements were made at a distance of 1 cm from the proximal surgical margin, from the middle part of the specimen, and 1 cm from the distal surgical margin in the gastric specimen and the results were compared.

RESULTS

A total of 132 patients were included in the study, 44 patients in each group. Microscopically measured antrum mucosal thickness was found to be statistically significantly higher in group 2 compared to other groups (groups 1.15, 1.35, 1.16 mm, respectively, p = 0.000). There was no difference between the groups in terms of early complications such as bleeding, wound site infection, or leakage from the staple line within the first 28 days after surgery.

CONCLUSION

This study found that LSG had no effect on early complications due to Hp positivity or eradication of Hp.

KEY POINTS

• The presence of HP increases the wall thickness of the gastric antrum mucosa. • After HP eradication, stomach antrum wall thickness returns to normal. • HP eradication before LSG reduces the wall thickness of the gastric antrum mucosa. • It was determined that HP scanning and eradication before LSG had no effect on postoperative complications.

Seven-day triple therapy is sufficient to eradicate infection caused by Helicobacter pylori without 23S rRNA point mutation

ABSTRACT

Tailored therapy based on dual priming oligonucleotide-based polymerase chain reaction (DPO-PCR) can be considered an alternative to overcome the low eradication rate in high clarithromycin-resistance areas. The triple therapy (TT) duration of the tailored approach in most studies was 7 days for patients without point mutation. However, recent western guidelines have recommended a treatment duration of 14 days. The aim of this study was to compare the success rate of 7 and 14 days of TT for eradicating Helicobacter pylori without point mutation, as determined by DPO-PCR.Between Feb 2016 and Feb 2019, medical records of patients who underwent DPO-PCR were reviewed. Patients without point mutation as determined by DPO-PCR were enrolled in this study. The eradication success rate and adverse events were evaluated.A total of 366 patients without A2142G and A2143G point mutation were enrolled. The success rates of 7-day and 14-day TT were 88.4% (168/190) and 85.9% (151/176) by intention to treat analysis (P = .453) and 90.8% (168/185) and 90.4% (151/167) by per-protocol analysis (P = .900), respectively. The adverse event rates showed no significant difference between the 2 groups.In patients without point mutation based on DPO-PCR results, 7-day TT is as effective as 14-day TT. Therefore, 7 days may be considered as a cost-effective treatment duration in Korea.

Helicobacter Pylori Eradication Therapy: Still a Challenge

Introduction

Helicobacter pylori (H. pylori) infection is prevalent worldwide. H. pylori therapies' adverse effects can contribute to noncompliance among patients. This study aimed to assess the association between compliance to H. pylori eradication therapy and adverse effects using various drug regimens.

Method

We conducted an observational study from September 2017 to February 2020 in two tertiary care hospitals in patients with dyspeptic symptoms. H. Pylori detection was done by histopathological examination of gastric mucosa during upper gastrointestinal endoscopy or stool for H. pylori antigen. Patients with positive results were randomly assigned one of the nine different regimens consisting of a combination of proton pump inhibitors along with at least two antibiotics. The antibiotics used in different combinations were amoxicillin, clarithromycin, metronidazole, doxycycline, levofloxacin, and bismuth sulfate. The treatment groups received standard triple therapy with and without probiotics, sequential, concomitant, levofloxacin-based triple therapy, or sequential and bismuth-based quadruple treatments. All treatments were given for two weeks. At the end of the treatment period, patients were interviewed about completing treatment and any adverse effects they may have experienced during therapy. Data were analyzed using IBM Statistical Package for the Social Sciences (SPSS) Statistics for Windows, Version 22.0 (Armonk, NY: IBM Corp.).

Results

A total of 250 patients were included in the study (62% males, 38% females) with a mean age of 37 years ± 13 years (range 12-84 years). Most patients completed the treatment regimen (80.4%), and 19.6% did not complete treatment because of adverse effects (p<0.005). The levofloxacin-based, concomitant, and standard triple regimen with probiotic treatments had the highest tolerance (≥85%). Common adverse effects were abdominal and epigastric pain (11%), alteration of taste, and diarrhea (6.5%).

Conclusion

H. pylori eradication therapy is always a challenge. Patient compliance to the treatment can only be ensured by medicines with fewer adverse effects. In our study, levofloxacin-based triple, concomitant, and standard triple regimens with probiotics are maximally acceptable treatments.

Sequential Helicobacter pylori eradication therapy in Myanmar; a randomized clinical trial of efficacy and tolerability

BACKGROUND AND AIM

There is little published research to examine the best approach to the management of Helicobacter pylori in Myanmar. This study aimed to determine the relative efficacy and tolerability of sequential eradication therapy compared to Myanmar's current recommendation of a concomitant four drug regimen.

METHODS

Patients were screened for H. pylori using monoclonal Stool Antigen Testing (SAT). Those testing positive were randomized 1:1 to receive receive Myanmar's first-line regimen of 14 days of concomitant rabeprazole, clarithromycin, amoxycillin and tinidazole (140 pills, cost US$23) or 10 days of sequential rabeprazole, clarithromycin, amoxycillin and tinidazole (60 pills, cost US$10). Adherence and adverse effects were recorded, and the efficacy of the regimens assessed with repeat SAT.

RESULTS

Of the 1011 patients screened for H. pylori infection, 313 (31%) tested positive. There was no statistical difference in the cure rates of the two regimens in either intention-to-treat: 128/157 (82%; 95% confidence interval (CI): 75-87%) receiving sequential therapy versus 123/156 (79%; 95% CI: 72-85%) receiving concomitant therapy (P = 0.55) or per-protocol analysis: 125/131 (95%; 95% CI: 90-98) receiving sequential therapy versus 121/130 (93%; 95% CI: 87-96) receiving concomitant therapy (P = 0.42). Side effects of therapy were reported in 54/157 (47%) patients taking sequential therapy compared with 62/156 (53%) taking concomitant therapy, but this difference did not reach statistical significance (P = 0.33).

CONCLUSIONS

In this high-burden, resource-poor setting, less expensive sequential therapy was as effective and as well tolerated as the currently recommended concomitant four drug regimen for eradication of H. pylori.

Standard triple therapy in Helicobacter pylori eradication in Turkey: Systematic evaluation and meta-analysis of 10-year studies

BACKGROUND/AIMS

This study aims at evaluating the mean eradication rate by a systematic compilation of the studies which involved the standard triple therapy (STT) in first-line Helicobacter pylori (Hp) eradication in Turkey over a period of 10 years between 2004 and 2013 using the meta-analysis method.

MATERIALS AND METHODS

The systematic compilation and meta-analysis were carried out according to the PRISMA standards defined in the Cochrane handbook. The results of full-text studies published in national and international journals in English and Turkish languages on Turkish population in a period of 10 years, from 2004 to 2013, are included in this study. The studies include open-label trials, controlled trials, treatment arms, and case series that included a triple therapy regimen consisting of standard doses of a proton pump inhibitor (PPI; omeprazole 20 mg BID, lansoprazole 30 mg BID, pantoprazole 40 mg BID, esomeprazole 40 mg BID, or rabeprazole 20 mg BID) along with clarithromycin 500 mg BID and amoxicillin 1 g BID for 7-14 days. They were scanned electronically via the search engines Google Scholar, PubMed, and the Turkish Medicine Index using specific keywords. The related keywords used were Turkey, Helicobacter pylori, infection, standard triple treatment, first-line therapy, eradication, omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole, clarithromycin, and amoxicillin. Studies carried out with adults were included in the evaluation. The publication year of the studies and the included number of patients, their age, gender, treatment duration (7, 10, and 14 days), and PPIs used were evaluated by two separate gastroenterologists and biostatisticians. Studies that used at least one reliable method (histology, urea breath test (UBT), or Helicobacter pylori stool antigen (HpSA) test) four weeks after completing the treatment for the control of Hp eradication were included. Only naive patients were accepted, and patients who had previously received eradication treatment were excluded. The effectiveness of the Hp eradication was analyzed using an intention-to-treat (ITT) or per-protocol (PP) analysis.

RESULTS

The STT regime of 45 studies complying with the inclusion criteria was evaluated. A total of 3715 patients were included in the study. Of the 3010 patients whose gender information was available, 55% were women and 45% were men; the weighted age average given explicitly in the studies was 42.14±0.67. The treatment lasted for 14 days in 42 studies, for 7 days in six studies, and for 10 days in 1 study. The eradication rates evaluated according to the ITT and PP analyses were 60% (95% CI: 56%-63%) and 57% (95% CI: 51%-62%), respectively. The rates for 7 days of treatment were 57% (95% CI: 46%-68%) and 60% (95% CI: 51%-67%) and for 14 days of treatment were 60% (95% CI: 56%-63%) and 56% (95% CI: 50%-62%), respectively. The ITT eradication rate of the only 10-day study was 78% (95% CI: 66%-86%). In the meta-regression analysis, the treatment duration, PPI, age, and gender ratio (women/men) used for the ITT analysis had no effect. The gender ratio and age were not considered in this analysis because they were not clearly stated in studies using the PP analysis. The duration of treatment and the PPI used had no effect.

CONCLUSION

A systematic meta-analysis of studies conducted during the period 2004-2013 in Turkey revealed that the rate of first-line Hp eradication using STT was unacceptably low, and the duration of treatment and PPI used made no difference.

Helicobacter pylori infection is an infectious disease and the empiric therapy paradigm should be changed

Helicobacter pylori infection is an infectious disease. Given the alarmingly high antibiotic resistance in H. pylori, gastroenterologists should change the empiric H. pylori treatment paradigm to an antimicrobial susceptibility testing-guided precision treatment. Antimicrobial stewardship programs for H. pylori should be implemented locally, regionally, and nationally to monitor the antibiotic resistance pattern.

The Gastro-protective Effect of Ginger (Zingiber officinale Roscoe) in Helicobacter pylori Positive Functional Dyspepsia

Purpose: The present study aimed to assess the effect of ginger (Zingiber officinale) powder supplementation on Helicobacter pylori eradication and improvement of dyspeptic symptoms in patients with H. pylori positive functional dyspepsia (FD). Methods: During this pilot study 15 patients with H. pylori positive FD received 3 g/d ginger powder as three 1-g tablets for 4-weeks. Dyspepsia symptoms were asked before and after the intervention using a questionnaire based on the Rome III criteria. H. pylori eradication was also assessed by a non-invasive stool antigen (HpSAg) test. Results: Ginger consumption accompanied by significant H. pylori eradication rate of 53.3% (P = 0.019) and the odds ratio (95% CI) was 8 (1.07 to 357.14). Moreover, our results showed significant changes in most of the dyspepsia symptoms after ginger supplementation. Conclusion: According to our findings, Z. officinale can be considered as a useful complementary therapy for FD. However, due to the small number of clinical trials in this area, further welldesigned clinical trials are needed to explicitly talk about its effectiveness especially about the eradication of H. pylori.

Innovative Perspectives of Integrated Chinese Medicine on H. pylori

Helicobacter pylori (H. pylori) treatment requires the development of more effective therapies, mainly owing to the challenges posed by the bacterial resistance to antibiotics. In China, critically high infection and antibiotic resistance rates have limited the application of classic H. pylori eradication therapies. Consequently, researchers are attempting to find new solutions by drawing from traditional medicine. This article reviews basic scientific and clinical progress in the use of integrated Chinese and Western medicine (IM) to treat H. pylori; describes the conflicting results between in vivo and in vitro studies in this regard; discusses the observed clinical effects of IM, with emphasis on traditional patent medicines; and proposes a role for IM in both the diagnosis and treatment of H. pylori, including the use of tongue manifestation as an early diagnostic method and capitalizing on IM's direct and indirect methods for enhancing antibiotic effect.

rdxA, frxA, and efflux pump in metronidazole-resistant Helicobacter pylori: Their relation to clinical outcomes

BACKGROUND AND AIM

rdxA and frxA mutations and enhancement of efflux pump have been suggested as the cause of metronidazole resistance in Helicobacter pylori. This study was performed to investigate the resistance mechanisms related to clinical eradication outcome, and to examine direct involvement of hefA in metronidazole-resistant isolates with intact rdxA and frxA.

METHODS

A total of 53 H. pylori-positive patients who were treated with metronidazole-containing sequential or quadruple therapy from 2011 to 2015 were enrolled. The metronidazole susceptibility of H. pylori isolates was examined by agar dilution test. Mutations in rdxA and frxA, were analyzed with DNA sequencing, and impact of hefA on metronidazole resistance was examined with quantitative real-time reverse transcription polymerase chain reaction, knockout and genetic complementation test for hefA.

RESULTS

Seven mutation types of rdxA and/or frxA were found in H. pylori isolated from non-eradicated subjects. rdxA mutation was associated with eradication failure (P = 0.002), and nonsense mutation in rdxA reduced eradication efficacy (P = 0.009). hefA expression was significantly higher in resistant isolates (P < 0.001), especially in rdxA(-)frxA(-) as compared to rdxA(+)frxA(+) (P = 0.027). Resistant isolates with no mutation in rdxA and frxA became susceptible after hefA knockout. Genetic complementation for hefA recovered metronidazole resistance in all of three hefA knockout mutants.

CONCLUSIONS

These results suggest that rdxA mutations play a critical role in metronidazole resistance as well as the outcomes of eradication therapy. In addition, hefA seems to be directly involved in metronidazole resistance, which explains the resistance in clinical isolates with intact rdxA and frxA.

[The Efficacy of Moxifloxacin-containing Triple Therapy after Hybrid Therapy Failure in Helicobacter pylori Eradication]

Background/Aims

Hybrid therapy was successful in eradicating Helicobacter pylori (H. pylori) according to previous reports. However, to the best of our knowledge, there have only been a few studies evaluating the optimal choice after hybrid failure. Hence, we aimed to evaluate the efficacy of moxifloxacin-containing triple therapy after hybrid therapy failure in H. pylori eradication.

Methods

Between January 2013 and March 2016, we retrospectively reviewed patients who underwent failed hybrid therapy, as first line treatment, in eradicating H. pylori (rabeprazole and amoxicillin b.i.d for 14 days, in addition to clarithromycin and metronidazole b.i.d for final 7 days). Then, we investigated the eradication rates of moxifloxacin-containing triple therapy (rabeprazole, amoxicillin b.i.d and moxifloxacin qd) as the second line of treatment. Intention-to-treat (ITT) and per-protocol (PP) analyses were used to determine the eradication rate. We evaluated the status of H. pylori by using ¹³C-urea breath test 6 weeks after the final treatment. Moreover, compliance and adverse effects of each patient were analyzed.

Results

Among those who failed the initial hybrid therapy, 11 patients received moxifloxacin-containing triple therapy. The overall eradication rates, as determined by ITT and PP, were 72.7% (n=8/11) and 80% (n=8/10), respectively. The compliance rate was 100%, and there were no serious adverse effects.

Conclusions

Moxifloxacin-containing triple therapy can be used as a second line therapy in case of hybrid therapy failure. A large scale study is necessary to confirm the findings of this study and establish clinical evidence.

Efficacy and safety of rifaximin associated with standard triple therapy (omeprazole, clarithromycin and amoxicillin) for H. pylori eradication: A phase IV pilot clinical trial

BACKGROUND

A progressive decrease in Helicobacter pylori eradication rates has been described over the years, driving the need for new antibiotic treatments.

AIM

To evaluate the efficacy and safety of the addition of rifaximin (Spiraxin^®) to standard triple therapy (omeprazole, amoxicillin and clarithromycin) for the eradication of H. pylori.

METHODS

Independent prospective clinical trial (EUDRACT no.: 2013-001080-23). Forty consecutive adult patients were included with H. pylori infection, dyspeptic symptoms and naive to eradication treatment. A full blood test was performed in the first five patients enrolled to evaluate the safety of the treatment. H. pylori eradication was confirmed with the ¹³C-urea breath test at least four weeks after the end of treatment with rifaximin 400mg/8h, clarithromycin 500mg/12h, amoxicillin 1g/12h and omeprazole 20mg/12h for 10 days.

RESULTS

Forty patients were consecutively enrolled, 53% woman, mean age 44 years. Indication for eradication: 60% non-investigated dyspepsia, 38% functional dyspepsia and 2% gastric ulcer. Four patients did not attend the eradication confirmatory breath test. The eradication rate was 61% (95% CI: 45-77%) for the protocol and 55% (40-70%) for intention-to-treat. About 76% of the patients experienced adverse events (35% diarrhea, 14% nausea and 24% metallic taste), none of which was serious. The blood tests did not show significant alterations.

CONCLUSION

Acceptable H. pylori eradication rates are not achieved with rifaximin associated with standard triple therapy for 10 days.

Update on the first-line treatment for Helicobacter pylori infection - a continuing challenge from an old enemy

Because the prevalence of antibiotic resistance markedly increases with time worldwide, anti-H. pylori treatment is continuing to be a great challenge forsphysicians in clinical practice. The Real-world Practice & Expectation of Asia-Pacific Physicians and Patients in Helicobacter Pylori Eradication (REAP-HP) Survey demonstrated that the accepted minimal eradication rate of anti-H. pylori regimen in H. pylori-infected patients was 91%. The Kyoto Consensus Report on Helicobacter Pylori Gastritis also recommended that, within any region, only regimens which reliably produce eradication rates of ≥90% in that population should be used for empirical treatment. This article is aimed to review current first-line eradication regimens with a per-protocol eradication rate exceeding 90% in most geographic areas. In regions with low (≦15%) clarithromycin resistance, 14-day hybrid (or reverse hybrid), 10 ~ 14-day sequential, 7 ~ 14-day concomitant, 10 ~ 14-day bismuth quadruple or 14-day triple therapy can achieve a high eradication rate in the first-line treatment of H. pylori infection. However, in areas with high (>15%) clarithromycin resistance, standard triple therapy should be abandoned because of low eradication efficacy, and 14-day hybrid (or reverse hybrid), 10 ~ 14-day concomitant or 10 ~ 14-day bismuth quadruple therapy are the recommended regimens. If no recent data of local antibiotic resistances of H. pylori strains are available, universal high efficacy regimens such as 14-day hybrid (or reverse hybrid), concomitant or bismuth quadruple therapy can be adopted to meet the recommendation of consensus report and patients' expectation.

Triple therapy versus sequential therapy for the first-line Helicobacter pylori eradication

Background

The eradication rate of Helicobacter pylori (H. pylori) with triple therapy which was considered as standard first-line treatment has decreased to 70–85%. The aim of this study is to compare 7-day triple therapy versus 10-day sequential therapy as the first line treatment.

Methods

Data of 1240 H. pylori positive patients treated with triple therapy or sequential therapy from January 2013 to December 2015 were analyzed retrospectively. The patients who had undertaken previous H. pylori eradication therapy or gastric surgery were excluded.

Results

There were 872 (74.3%) patients in the triple therapy group, and 302 (25.7%) patients in the sequential therapy group. There was no significant difference between the two groups regarding age, residence, comorbidities or drug compliance, but several differences were noted in endoscopic characteristics and indication for the treatment. The eradication rate of H. pylori by intention to treat analysis was 64.3% in the triple therapy group, and 81.9% in the sequential therapy group (P = 0.001). In per protocol analysis, H. pylori eradication rate in the triple therapy and sequential therapy group was 81.9 and 90.3%, respectively (P = 0.002). There was no significant difference in overall adverse events between the two groups (P = 0.706). For the rescue therapy, bismuth-containing quadruple therapy showed comparable treatment efficacy after sequential therapy, as following triple therapy.

Conclusions

The eradication rate of triple therapy was below the recommended threshold. Sequential therapy could be effective and tolerable candidate for the first-line H. pylori eradication therapy.

Human Lysozyme Synergistically Enhances Bactericidal Dynamics and Lowers the Resistant Mutant Prevention Concentration for Metronidazole to Helicobacter pylori by Increasing Cell Permeability

Metronidazole (MNZ) is an effective agent that has been employed to eradicate Helicobacter pylori (H. pylori). The emergence of broad MNZ resistance in H. pylori has affected the efficacy of this therapeutic agent. The concentration of MNZ, especially the mutant prevention concentration (MPC), plays an important role in selecting or enriching resistant mutants and regulating therapeutic effects. A strategy to reduce the MPC that can not only effectively treat H. pylori but also prevent resistance mutations is needed. H. pylori is highly resistant to lysozyme. Lysozyme possesses a hydrolytic bacterial cell wall peptidoglycan and a cationic dependent mode. These effects can increase the permeability of bacterial cells and promote antibiotic absorption into bacterial cells. In this study, human lysozyme (hLYS) was used to probe its effects on the integrity of the H. pylori outer and inner membranes using as fluorescent probe hydrophobic 1-N-phenyl-naphthylamine (NPN) and the release of aspartate aminotransferase. Further studies using a propidium iodide staining method assessed whether hLYS could increase cell permeability and promote cell absorption. Finally, we determined the effects of hLYS on the bactericidal dynamics and MPC of MNZ in H. pylori. Our findings indicate that hLYS could dramatically increase cell permeability, reduce the MPC of MNZ for H. pylori, and enhance its bactericidal dynamic activity, demonstrating that hLYS could reduce the probability of MNZ inducing resistance mutations.

Standard triple therapy versus sequential therapy for eradication of Helicobacter pylori in treatment naïve and retreat patients

BACKGROUND AND STUDY AIMS

Untreated Helicobacter pylori infection causes increased risk of gastric cancer, GI morbidity and mortality. Standard treatment for eradication of Helicobacter pylori infection, is the triple therapy which consists of a proton pump inhibitor; together with two antibiotics (amoxicillin 1000mg with clarithromycin 500mg or metronidazole 400mg) given twice daily for 7-14days. Recent evidence revealed, that cure rates of Helicobacter pylori infection with triple therapy had fallen below satisfactory targets. Sequential therapy consisting of a twice daily dose of a PPI for ten days with Amoxicillin given at 1000mg twice daily in the first 5days followed by clarithromycin 500mg and Metronidazole 400mg given twice daily in the subsequent 5days, was recommended to improve eradication rates. We performed a randomised open label study to compare the efficacy of sequential against triple therapy in Helicobacter pylori naive and retreat patients.

PATIENTS AND METHODS

In a randomised open label observational study 485 patients fulfilling inclusion and exclusion criteria were randomly assigned to be treated with triple therapy (n=231) or sequential therapy (n=254). Eradication of Helicobacter pylori was documented with ¹⁴C Urea breath test (UBT) performed 6weeks after the treatment.

RESULTS

The intention-to-treat eradication rate was better in sequential therapy group 84.6% than triple therapy 68% (p<0.001). Eradication rates were significantly higher for treatment naive than retreat patients in triple therapy group (70.5% and 58.3%, respectively, p<0.01). A trend of a better response was observed in eradication rate for treatment naive 88.55% versus retreat 74.6% in sequential therapy group but was not statistically significant (p=0.76). Compliance was similar in the two groups, however side effects were less and the clinical response was better in the sequential therapy group.

In vitro effect of clarithromycin and alginate lyase against helicobacter pylori biofilm

It is now established that the gastric pathogen Helicobacter pylori has the ability to form biofilms in vitro as well as on the human gastric mucosa. The aim of this study is to evaluate the antimicrobial effects of Clarithromycin on H. pylori biofilm and to enhance the effects of this antibiotic by combining it with Alginate Lyase, an enzyme degrading the polysaccharides present in the extracellular polymeric matrix forming the biofilm. We evaluated the Clarithromycin minimum inhibition concentration (MIC) on in vitro preformed biofilm of a H. pylori. Then the synergic effect of Clarithromycin and Alginate Lyase treatment has been quantified by using the Fractional Inhibitory Concentration index, measured by checkerboard microdilution assay. To clarify the mechanisms behind the effectiveness of this antibiofilm therapeutic combination, we used Atomic Force Microscopy to analyze modifications of bacterial morphology, percentage of bacillary or coccoid shaped bacteria cells and to quantify biofilm properties. © 2016 American Institute of Chemical Engineers Biotechnol. Prog., 32:1584-1591, 2016.

Evaluation of Clarithromycin Resistance Among Iranian Helicobacter pylori Isolates by E-Test and Real-Time Polymerase Chain Reaction Methods

Background

Helicobacter pylori is an important pathogen of human gastric mucosa. Antibiotic resistance, especially resistance to clarithromycin is a major factor for treatment failure of H. pylori infections. The main mechanism of clarithromycin resistance in these bacteria is related to point mutations in three different locations of 23S rRNA gene.

Objectives

The aims of this study were to evaluate the resistance rate to clarithromycin among local H. pylori isolates by the E-test method and to determine the profile of point mutation in 23S rRNA by real-time polymerase chain reaction (PCR) method.

Patients and Methods

Eighty biopsy samples were collected from dyspeptic patients by endoscopy during 2011 - 2012. All samples were homogenized immediately and cultured on supplemented brucella blood agar and incubated under microaerophilic conditions. Further biochemical tests and ureC gene PCR was done for H. pylori confirmation. The H. pylori OC1096 strain was used as the control strain, simultaneously. Frequency of clarithromycin resistance was determined by the E-test method based on the clinical and laboratory standard institute (CLSI) standards. Point mutation profile was determined by real-time PCR and further analysis of melting curve, amplicon sequencing was done continuously.

Results

From 80 biopsy samples, 20 positive H. pylori isolates were detected and confirmed by biochemical tests and PCR method. Overall, 21.7% of the H. pylori isolates, showed clarithromycin resistance phenotype by use of the E-test. Also, the minimal inhibitory concentration of clarithromycin was determined as ≥ 0.5 mg/L by the E-test method. Only point mutation in the location of A2143G with melting temperature of 54.7°C was observed in all resistant isolates.

Conclusions

This study showed that the frequency of H. pylori clarithromycin resistance in Iran is relatively high. Since clarithromycin is not commonly used in Iran for H. pylori eradication, the high rate of resistance could be related to cross-reactivity between other macrolides. Therefore, macrolide antibiotics must be prescribed with precaution in any case of treatment other than H. pylori infections. All resistant isolates showed A2143G mutation in 23S rRNA as the dominant pattern of point mutation at least in Tehran H. pylori isolates.

HIV-Helicobacter pylori Co-Infection: Antibiotic Resistance, Prevalence, and Risk Factors

Background

Patients infected with human immunodeficiency virus (HIV) are living longer due to the availability of more potent treatments. However, prescription of antibiotics to treat or prevent infections in these patients may increase the likelihood of co-infection with antibiotic-resistant species.

Aim

To compare antimicrobial susceptibility of Helicobacter pylori (H. pylori) in HIV-positive and HIV-negative patients and assess risk-factors for resistance.

Methods

We prospectively collected data from consecutive HIV-positive and HIV-negative patients undergoing upper gastrointestinal endoscopy. Patients with H. pylori-positive gastric biopsies who had never received H. pylori treatment were included.

Results

Of the 353 patients included, 93 were HIV-positive and 260 HIV-negative. Among the HIV-positive patients, 56 (60%) had been infected for <10 years, the median CD4+ count was 493 cells/μl and median viral load was 61 copies/mL; 66 (71%) were receiving antiretroviral therapy. HIV-positive patients were more often male (p = 0.009), had a lower body mass index (p<0.0001), and had less frequently received antibiotics during the 12-months prior to the endoscopy (p<0.0001) than HIV-negative patients. HIV-positive patients were more likely to have H. pylori resistant to levofloxacin (p = 0.0004), metronidazole (p = 0.01), or multiple antibiotics (p = 0.006). HIV-positive Black Africans were more likely to have resistant strains than were HIV-negative Black Africans (p = 0.04). Ethnicity and HIV status were independent risk factors for H. pylori resistance in all patients and acquired immune deficiency syndrome (AIDS) and sex were risk factors in HIV-positive patients.

Conclusions

There was a higher prevalence of primary H. pylori-resistant strains in HIV-positive than in HIV-negative patients. AIDS and sex were predictors of H. pylori resistance in HIV-positive patients.

Hybrid vs sequential therapy for eradication of Helicobacter pylori in Taiwan: A prospective randomized trial

AIM: To evaluate the efficacy of sequential vs hybrid therapy in patients with Helicobacter pylori (H. pylori) infection.

METHODS: From March 2013 to May 2014, one hundred and seventy-five H. pylori infected patients who had not been treated for H. pylori before were randomized to receive either sequential therapy (rabeprazole 20 mg and amoxicillin 1 g twice daily for 5 d, followed by rabeprazole 20 mg, clarithromycin 500 mg and metronidazole 500 mg twice daily for 5 d) or hybrid therapy (rabeprazole 20 mg and amoxicillin 1 g for 7 d, followed by rabeprazole 20 mg, amoxicillin 1 g, clarithromycin 500 mg and metronidazole 500 mg twice daily for 7 d). H. pylori status was confirmed by positive results of both rapid urease test and histology examination or a positive result of culture. Eradication efficacy was assessed by follow-up endoscopy with rapid urease test and histological examination 8 wk after the end of anti-H. pylori therapy, or ¹³C-urea breath test at least 4 wk after completion of treatment. The primary outcome was H. pylori eradication by intension-to-treat (ITT) and per-protocol (PP) analyses.

RESULTS: One hundred and sixty-seven patients (83 patients in the sequential group and 84 patients in the hybrid group) completed the study. The compliance rates were 97.6% and 97.7% for the two groups, respectively. The eradication rate was 78.2% for the sequential group and 92% for the hybrid group by ITT analysis (P = 0.01). The eradication rate was 81.9% for the sequential group and 96.4% for the hybrid group by PP analysis (P = 0.01). Univariate analysis for the clinical and bacterial factors did not identify any risk factors associated with treatment failure. Severe adverse events were observed in 2.3% of patients in the sequential group and 2.4% of those in the hybrid group.

CONCLUSION: Due to a grade A (> 95%) success rate for H. pylori eradication by PP analysis, similar compliance and adverse events, hybrid therapy seems to be an appropriate eradication regimen in Taiwan.

Systematic review and meta-analysis: full- vs. half-dose anti-microbials in clarithromycin-based regimens for Helicobacter pylori eradication

BACKGROUND

Half-dose regimens may be equally effective but associated with diminished adverse events (AE) than standard-dose regimens.

AIM

To assess efficacy and safety of full- vs. half-dose clarithromycin in the treatment of H. pylori.

METHODS

Medline, EMBASE and PubMed databases were searched for randomised controlled trials (RCTs) that meet eligibility criteria. Only parallel group RCTs with ≥ 2 arms were eligible. Studies comparing triple, quadruple or sequential therapy for 7-14 days were selected. Regimens had to contain the same drug combination, differing only in dosage; the comparison of full- vs. half-dose clarithromycin was required, regardless if other drugs were dose-reduced or not. Data extraction was performed for primary outcome [eradication by intent-to-treat (ITT) and per-protocol (PP) analyses] and secondary outcome (AE).

RESULTS

A total of 1622 articles were identified, of which 19 studies were eligible. Overall, eradication was achieved in 82.5% of half-dose (n = 2115) vs. 83.4% of full-dose recipients (n = 2109) on ITT (87.1% vs. 88.4% on PP respectively). Pooled relative risk in the half- vs. full-dose regimen was 0.98 (95% CI: 0.95-1.02) on ITT and 0.99 (95% CI: 0.97-1.01) on PP by the random effects model. Heterogeneity was significant (chi-squared statistic P = 0.05, I(2) = 37%). AE were reported in 29.3% of half- vs. 44.0% of full-dose recipients [pooled RR 0.67 (95% CI: 0.60-0.75)]. Pre-planned subgroup analyses of dose modification, sample size, study origin and treatment duration, as well as sensitivity analysis showed no significant differences between arms.

CONCLUSION

A half-dose clarithromycin-based regimen is equally effective yet better tolerated than its full-dose counterpart in the treatment of H. pylori.

Efficacy of moxifloxacin-based sequential therapy for first-line eradication of Helicobacter pylori infection in gastrointestinal disease

AIM: To evaluate the efficacy of 14-d moxifloxacin-based sequential therapy as first-line eradication treatment of Helicobacter pylori (H. pylori) infection.

METHODS: From December 2013 to August 2014, 161 patients with confirmed H. pylori infection randomly received 14 d of moxifloxacin-based sequential group (MOX-ST group, n = 80) or clarithromycin-based sequential group (CLA-ST group, n = 81) therapy. H. pylori infection was defined on the basis of at least one of the following three tests: a positive ¹³C-urea breath test; histologic evidence of H. pylori by modified Giemsa staining; or a positive rapid urease test (CLOtest; Delta West, Bentley, Australia) by gastric mucosal biopsy. Successful eradication therapy for H. pylori infection was defined as a negative ¹³C-urea breath test four weeks after the end of eradication treatment. Compliance was defined as good when drug intake was at least 85%. H. pylori eradication rates, patient compliance with drug treatment, adverse event rates, and factors influencing the efficacy of eradication therapy were evaluated.

RESULTS: The eradication rates by intention-to-treat analysis were 91.3% (73/80; 95%CI: 86.2%-95.4%) in the MOX-ST group and 71.6% (58/81; 95%CI: 65.8%-77.4%) in the CLA-ST group (P = 0.014). The eradication rates by per-protocol analysis were 93.6% (73/78; 95%CI: 89.1%-98.1%) in the MOX-ST group and 75.3% (58/77; 95%CI: 69.4%-81.8%) in the CLA-ST group (P = 0.022). Compliance was 100% in both groups. The adverse event rates were 12.8% (10/78) and 24.6% (19/77) in the MOX-ST and CLA-ST group, respectively (P = 0.038). Most of the adverse events were mild-to-moderate in intensity; there was none serious enough to cause discontinuation of treatment in either group. In multivariate analysis, advanced age (≥ 60 years) was a significant independent factor related to the eradication failure in the CLA-ST group (adjusted OR = 2.13, 95%CI: 1.97-2.29, P = 0.004), whereas there was no significance in the MOX-ST group.

CONCLUSION: The 14-d moxifloxacin-based sequential therapy is effective. Moreover, it shows excellent patient compliance and safety compared to the 14-d clarithromycin-based sequential therapy.

Effect of Alginate Lyase on Biofilm-GrownHelicobacter pyloriProbed by Atomic Force Microscopy

Helicobacter pylori(H. pylori) is a microorganism with a pronounced capability of adaptation under environmental stress solicitations. Its persistence and antimicrobial resistance to the drugs commonly used in the anti-H. pyloritherapy are associated with the development of a biofilm mainly composed of DNA, proteins, and polysaccharides. A fundamental step to increase the success of clinical treatments is the development of new strategies and molecules able to interfere with the biofilm architecture and thus able to enhance the effects of antibiotics. By using Atomic Force Microscopy and Scanning Electron Microscopy we analyzed the effects of the alginate lyase (AlgL), an enzyme able to degrade a wide class of polysaccharides, on theH. pylorishape, surface morphology, and biofilm adhesion properties. We demonstrated that AlgL generates a noticeable loss ofH. pyloricoccoid form in favor of the bacillary form and reduces theH. pyloriextracellular polymeric substances (EPS).

Effect of licorice versus bismuth on eradication of Helicobacter pylori in patients with peptic ulcer disease

Background:

Different therapeutic regimens were used for eradication of Helicobacter pylori, based on the cost, effectiveness and patient's compliance. The aim of this study was the evaluation of licorice compared with bismuth in quadruple regimen on eradication of H. pylori in patients with peptic ulcer disease (PUD).

Materials and Methods:

In a double-blind clinical trial study, 60 patients with PUD and positive rapid urease test were enrolled. The patients were randomly allocated into two equal groups. In first group, licorice, amoxicillin, metronidazole and omeprazole and in the second (control) group, bismuth subsalicylate, amoxicillin, metronidazole and omeprazole were prescribed respectively, and 4 weeks after treatment, in order to evaluate H. pylori eradication, urea breath test was done in all patients. The outcome of the study was the preference usage of licorice as an effective medication for H. pylori eradication.

Results:

Mean age of the patients in the control and case groups were 40.8 ± 15.5 and 42.2 ± 15.8 years, respectively (P = 0.726). Seventeen (56.7%) patients in control group and 16 (53.3%) in the case group were female (P = 0.795). Both groups were similar based on frequency of gastric or duodenal ulcer. Response to treatment were seen in 20 (67%) and 17 (57%) patients of case and control groups, respectively (P > 0.05).

Conclusion:

Our study showed that licorice is as effective as bismuth in H. pylori eradication; therefore, in patients whom bismuth is contraindicated, licorice can be used safely instead.

[Future trends of Helicobacter pylori eradication therapy in Korea]

The prevalence of Helicobacter pylori infection in Korea shows a decreasing trend and has changed to that of developed country, especially for those below 30 years old. However, the primary antibiotic resistance rates are higher than those of developed countries. The reason for the decrease in the efficacy of standard triple therapy is mainly due to the increase in the resistance against clarithromycin. Sequential therapy seems to be more effective than the standard triple therapy, but the intention-to-treat eradication rate of sequential therapy in Korea, which is mostly under 80.0%, is still not satisfactory. Therefore, a promising regimen is needed. Recently, the Japanese health insurance system admitted 'H. pylori-infected gastritis'as an indication of eradication. Furthermore, the Kyoto Consensus Meeting on H. pylori Gastritis held from January 30th to February 1st, 2014, proposed that 'all H. pylori positive patients should be offered to receive H. pylori eradication'. This suggests that the concept of eradication has been changed from 'treatment' to 'prevention'. Various individualized tailored therapy based on the polymorphism, age and other demographic factors and antibiotic resistance has been attempted to maximize H. pylori eradication therapy. The aim of this article is to review the current epidemiology, H. pylori resistance state, treatment guideline, and to assess the possible future strategy and treatment for H. pylori infection in Korea.

[Changes in the eradication rate of conventional triple therapy for Helicobacter pylori infection in Korea]

Although, the prevalence of Helicobacter pylori infection in Korea has declined owing to the eradication therapy, recent seropreva-lence of H. pylori infection is still reported to be as high as 54.4%. Until now, "standard regimen" for eradication of H. pylori has been conventional triple therapy consisting of proton pump inhibitor, amoxicillin, and clarithromycin. However, with the increase in antibiotic resistance, especially against clarithromycin, the eradication rate of conventional triple therapy has steadily declined during the past 13 years in Korea. Present eradication rate of standard triple therapy is reported to be less than 80%, which is the Maginot line of efficacy for the currently available regimen. Therefore, new first line eradication regimen is needed to enhance the eradication rate of H. pylori infection.

Second-line and third-line trial for helicobacter pylori infection in patients with duodenal ulcers: A prospective, crossover, controlled study

BACKGROUND

Following standard first-line triple therapies for Helicobacter pylori infection, up to 20% of patients require further eradication.

OBJECTIVE

The aim of this study was to assess the effects of second-line triple therapies and third-line quadruple therapies for the eradication of H pylori.

METHODS

This 7-week, prospective, crossover, controlled, second- and third-line trial was conducted at the Department of Gastroenterology, Ferencváros Health Center (Budapest, Hungary). Patients aged 18 to 80 years with duodenal ulcers and an H pylori infection resistant to first-line triple therapy (pantoprazole 40 mg BID + amoxicillin 1000 mg BID + clarithromycin 500 mg BID [PAC] given as tablets) received a different triple therapy regimen (ranitidine bismuth citrate 400 mg BID + metronidazole 500 mg BID + clarithromycin 500 mg BID [RBC-MC]) for 7 days (group 1A), and nonresponders after RBC + 2 antimicrobials received the pantoprazole-based regimen (group 1B). After secondary failure, patients were randomized to receive quadruple therapies: pantoprazole, amoxicillin, tetracycline, and either nitrofurantoin or bismuth subsalicylate (groups 2A and 2B).

RESULTS

One hundred thirty-four patients were enrolled in the second-line study (56 men, 78 women; mean [SD] age, 51.1 [12.4] years; group 1A, 68 patients; group 1B, 66 patients). Subsequently, 41 (30.6%) of these patients were randomized to receive quadruple therapies. Using intent-to-treat (ITT) analysis, the eradication rates did not differ significantly (60.3% and 65.2% in groups 1A and 1B, respectively; 61.9% and 55.0% in groups 2A and 2B, respectively). Perprotocol eradication rates did not differ significantly (66.1% and 68.3% in groups 1A and 1B, respectively); however, the rates were significantly different in group 2A (66.7%) versus group 2B (55.5%) (P = 0.03).

Adherence and barriers to H. pylori treatment in Arctic Canada

Introduction

Helicobacter pylori infection is an emerging health concern to some northern Canadian Aboriginal communities and their clinicians. Clinicians in the north perceive H. pylori infection to be a major clinical problem because they find H. pylori infection in many patients evaluated for common stomach complaints, leading to frequent demand for treatment, which often fails. Moreover, public health authorities identified the need for information to develop locally appropriate H. pylori control strategies. We described adherence and identified barriers to completing treatment among H. pylori-positive participants in a community-based project inspired by local concerns about H. pylori infection risks.

Methods

In 2008, 110 H. pylori-positive participants (diagnosed by a breath test, histopathology and/or culture) of the Aklavik H. pylori project were randomised to standard-of-care or sequential treatment. We ascertained adherence by interviewing participants using a structured questionnaire. We estimated adherence frequencies as the proportion of participants who reported taking either 100% of doses (perfect adherence) or ≥80% of doses (good adherence). To compare the proportion with perfect or good adherence in subgroups, we report proportion differences and 95% confidence intervals (CI).

Results

Of 87 participants who were interviewed, 64% reported perfect adherence and 80% reported good adherence. We observed more frequent perfect adherence for: standard therapy (67%) versus sequential (62%); males (76%) versus females (52%); participants 40–77 years (79%) versus 17–39 (50%). Proportion differences were 5% (CI: −15, 25) for standard versus sequential therapy; 23% (CI: 4, 43) for male versus female; and 29% (CI: 10, 48) for 40–77 versus 15–39 years for perfect adherence. Of the 29 participants who reported poor adherence (<80% of doses taken), the following barriers to treatment were reported: changed mind about taking treatment (24%), consumption of alcoholic beverages (18%), nausea (18%), forgetfulness (12%), stomach pain (12%), difficulty in swallowing pills (6%), no reason (6%) or bad taste of the pills (6%).

Conclusion

This analysis suggests that adherence to treatment for eliminating H. pyori infection may vary by regimen and may be influenced by socio-demographic factors. These findings add to the small body of evidence pertaining to adherence to H. pylori treatment in Arctic Aboriginal communities. On-going research in additional northern Canadian communities will accumulate data for developing recommendations to improve adherence for treatment to eliminate H. pylori infection.

[Clarithromycin-resistant Helicobacter pylori associated with 23S rRNA point mutations in Jeju Island]

BACKGROUND/AIMS

The point mutations in 23S rRNA gene accounts for the majority of the clarithromycin resistance of Helicobacter pylori. This study aimed to investigate the association between the clarithromycin-resistance of H. pylori and the failure of primary H. pylori eradication therapy in Jeju Island.

METHODS

Between April 2011 and October 2012, 6,937 patients underwent endoscopy, and H. pylori infection was evaluated in 2,287 patients (33.0%). Total of 110 patients with H. pylori infection were treated with proton pump inhibitor (PPI)-based triple therapy. The result of eradication was evaluated with urea breath test, histology and PCR which were conducted 4 weeks from the last dose of medicine.

RESULTS

The patients who had point mutations were 33 (26.0%). A2142G and A2143G mutations were observed in 10 patients (7.9%) and 23 patients (18.1%). Among 110 patients treated with PPI-based triple therapy, the success rate of the eradication therapy was 52.7% (58/110) and 70.7% (58/82) by intention-to-treat and per-protocol analysis, respectively. Fifteen of the 24 patients who failed the eradication therapy showed point mutations; 1 patient (4.2%) showed A2142G mutation and 14 patients (58.3%) showed A2143G mutation. Patients with A2143G mutation H. pylori showed higher failure rate of 87.5%. Patients with A2142G mutation H. pylori showed similar failure rate compared to those of the patients with wild type H. pylori.

CONCLUSIONS

In Jeju Island, the frequency of 23S rRNA point mutations is similar (26.0%) with other regions of Korea (15.8-31.3%). A2143G mutation is associated with the failure of H. pylori eradication.

Treatment for H. pylori infection: new challenges with antimicrobial resistance

The treatment of Helicobacter pylori infection is in a state of flux as traditional therapies fail and new therapies do not achieve the 90% eradication rates desired by clinicians. Triple therapy, which has been the mainstay of treatment in many countries over the last decade, now has suboptimal results in many parts of the world. A number of new treatments have been described with variable success in different parts of the world. In this article, the fundamentals of treatment for H. pylori treatment are reviewed and new treatment algorithms are proposed for regions of the world where triple therapy is failing. Sequential therapy and quadruple therapy (either bismuth-based or non-bismuth-based) are the best current options to replace initial treatment with triple therapy. When initial treatment fails, salvage treatments using rifabutin and levofloxacin are the best options. With knowledge of local resistance patterns and with meticulous confirmation of eradication with retreatment, most H. pylori infections can be successfully eradicated.

Effects of CYP2C19 loss-of-function variants on the eradication of H. pylori infection in patients treated with proton pump inhibitor-based triple therapy regimens: a meta-analysis of randomized clinical trials

Background

There are inconsistent conclusions about whether CYP2C19 variants could affect H. pylori eradication rate in patients treated with the proton pump inhibitor (PPI)-based therapy. We therefore performed a meta-analysis of randomized clinical trials (RCTs) to re-evaluate the impact of CYP2C19 variants on PPI-based triple therapy for the above indication.

Methods

All relevant RCTs in the PubMed, Cochrane Library, EMBASE, Web of Science and two Chinese databases (up to February 2013) were systematically searched, and a pooled analysis was performed with the odds ratio (OR) and 95% confidence interval (CI) by the STATA software.

Results

Sixteen RCT datasets derived from 3680 patients were included. There was no significant heterogeneity across the data available in this meta-analysis. There were significant differences in that rate between homozygous (HomEMs) and heterozygous (HetEMs) extensive metabolizers (OR 0.724; 95% CI 0.594–0.881), between HomEMs and poor metabolizers (PM) (OR 0.507; 95%CI 0.379–0.679), or between HetEMs and PMs (OR 0.688; 95%CI 0.515–0.920), regardless of the PPI being taken. Furthermore, sub-analysis of individual PPIs was carried out to explore the difference across all the PPIs used. A significantly low rate was seen in HomEMs vs. HetEMs taking either omeprazole (OR 0.329; 95%CI 0.195–0.553) or lansoprazole (OR 0.692; 95%CI 0.485–0.988), and also in HomEMs vs. PMs for omeprazole (OR 0.232; 95%CI 0.105–0.515) or lansoprazole (OR 0.441; 95%CI 0.252–0.771). However, there was no significant difference between HetEMs and PMs taking either one. No significant differences were observed for rabeprazole or esomeprazole across the CYP2C19 genotypes of interest.

Conclusions

Carriage of CYP2C19 loss-of-function variants is associated with increased H. pylori eradication rate in patients taking PPI-based triple therapies when omeprazole or lansoprazole is chosen. However, there is no a class effect after use of rabeprazole or esomeprazole.

Low rate of recurrence of Helicobacter pylori infection in spite of high clarithromycin resistance in Pakistan

BACKGROUND

The aim was to investigate the reinfection rate of H. pylori during a follow-up period of 12 months in adults who had undergone eradication therapy.

METHODS

One hundred-twenty patients; 116 with gastritis, 3 with duodenal ulcer and 1 gastric ulcer, were studied. Their mean age was 41±13 years (range 18-77) and male: female ratio of 2:1. H. pylori were cultured and antibiotic sensitivity was determined by Epsilometer test (E-test) for clarithromycin (CLR) and amoxicillin (AMX). Primers of urease C gene of H. pylori and Sau-3 and Hha I restriction enzymes were used for polymerase chain reaction-restriction fragment length polymorphism analysis (PCR-RFLP). 14C urea breath test (14C-UBT) was performed 4 weeks after the eradication therapy. The successfully treated patients were observed for 12 months with 14C-UBT to assess H. pylori status. If 14C-UBT was negative, it was repeated after every 12 weeks. If 14C-UBT was positive, endoscopy was repeated with biopsies.

RESULT

The eradication therapy was successful in 102(85%) patients. Out of forty-seven H. pylori isolates cultured, clarithromycin sensitivity was present in 30(64%) and amoxicillin in 45(98%), respectively. Follow-up 14C-urea breath tests of all 102 patients who eradicated H. pylori remained negative up to 9 months. However, in 6 patients, the 14C-UBT confirmed recurrence at 12 months. The recurrence rate was 6%.

CONCLUSION

A low rate of recurrence of H. pylori infection was found in patients with dyspeptic symptoms. H. pylori isolates demonstrated a high invitro clarithromycin resistance.

Comparative study of Helicobacter pylori eradication rates with 5-day quadruple "concomitant" therapy and 7-day standard triple therapy

BACKGROUND

Several studies have shown the superiority of concomitant quadruple therapy containing 3 antibiotics over triple therapy for Helicobacter pylori infection. The aim of this study was to compare concomitant quadruple therapy with standard triple therapy for first-line H. pylori eradication.

METHODS

A total of 270 patients with proven H. pylori infection were randomly assigned to one of 2 regimens: amoxicillin 1000 mg with clarithromycin 500 mg and lansoprazole 30 mg twice daily for 7 days (triple therapy) or amoxicillin 1000 mg with clarithromycin 500 mg, metronidazole 500 mg, and lansoprazole 30 mg twice daily for 5 days (concomitant therapy). The success of eradication was evaluated 4 to 5 weeks after completion of treatment.

RESULTS

Eradication rates were 86.1% in the triple therapy and 91.4% in the concomitant therapy (per protocol), but the difference was not statistically significant. Mild adverse events were more frequently reported in the concomitant-therapy group (35.6%) than in the triple-therapy group (25.2%) (P=0.09).

CONCLUSIONS

Five-day quadruple concomitant therapy eradicated H. pylori in over 90% of patients. Accordingly, concomitant therapy is thought to be a promising alternative to triple therapy as a first-line treatment regimen for H. pylori eradication.

Comparison of the Eradication Rate between 1- and 2-Week Bismuth-Containing Quadruple Rescue Therapies for Helicobacter pylori Eradication

BACKGROUND/AIMS

First-line therapies against Helicobacter pylori, including proton pump inhibitors (PPIs) plus two antibiotics, may fail in up to 20% of patients. 'Rescue' therapy is usually needed for patients who failed the first-line treatment. This study evaluated the eradication rate of bismuth-containing quadruple rescue therapy over a 1- or 2-week period.

METHODS

We prospectively investigated 169 patients with a persistent H. pylori infection after the first-line triple therapy, which was administered from October 2008 to March 2010. The patients were randomized to receive a 1- or 2-week quadruple rescue therapy (pantoprazole 40 mg b.i.d., tripotassium dicitrate bismuthate 300 mg q.i.d., metronidazole 500 mg t.i.d., and tetracycline 500 mg q.i.d.). After the 'rescue' therapy, the eradication rate, compliance, and adverse events were evaluated.

RESULTS

The 1-week group achieved 83.5% (71/85) and 87.7% (71/81) eradication rates in the intention to treat (ITT) and per-protocol (PP) analyses, respectively. The 2-week group obtained 87.7% (72/84) and 88.9% (72/81) eradication rate in the ITT and PP analyses, respectively. There was no significant difference in the eradication rate, patient compliance or rate of adverse events between the two groups.

CONCLUSIONS

One-week bismuth-containing quadruple therapy can be as effective as a 2-week therapy after the failure of the first-line eradication therapy.

[Clinical Usefulness of Antimicrobial Susceptibility Test for Helicobacter pylori.]

BACKGROUND

Antimicrobial resistance of Helicobacter pylori is considered as the main cause of failure of eradication therapy. Because resistance to metronidazole has been reported in 25.8% to 66.2% of H. pylori, a combination of proton pump inhibitors (PPI), amoxicillin, and clarithromycin is currently recommended as a primary therapy. We investigated the prevalence of antimicrobial resistance to the primary drugs and the impact of antimicrobial resistance on eradication rates.

METHODS

Between May and August 2005, H. pylori isolates from 93 patients were tested for antimicrobial susceptibility at Asan Medical Center. Susceptibility tests of clarithromycin and amoxicillin were performed by the disk diffusion method and those of metronidazole and tetracycline by Etest (AB Biodisk, Solna, Sweden). The medical records of the patients were reviewed to collect the data such as demographic findings, previous and current eradication therapies, and bacteriological outcome. The appropriate therapy was defined as three-drug-combination including susceptible drugs only, or four-drug-combination including metronidazole in the case of metronidazole-resistance.

RESULTS

Resistance rates to clarithromycin and metronidazole were 17.2% and 33.3%, respectively, but there was no resistance to tetracycline and amoxicillin. The eradication was successful in 32 of the 36 patients (88.9%) who received the appropriate therapy, but none of 4 patients who received an inappropriate therapy (P<0.01).

CONCLUSIONS

Resistance to clarithromycin seemed to increase and contribute to the failure of eradication therapy. For the appropriate therapy of H. pylori infection, the susceptibility results should be reported before initiation of the eradication therapy.

Update on non-bismuth quadruple (concomitant) therapy for eradication of Helicobacter pylori

BACKGROUND

Traditional standard triple therapy for Helicobacter pylori (H. pylori) infection (proton pump inhibitor-clarithromycin-amoxicillin) can easily be converted to non-bismuth quadruple (concomitant) therapy by the addition of a nitroimidazole twice daily.

AIM

To critically review evidence on the role of non-bismuth quadruple therapy (proton pump inhibitor-clarithromycin-amoxicillin-nitroimidazole) in the treatment of H. pylori infection.

METHODS

Bibliographical searches were performed in MEDLINE and relevant congresses up to December 2011. We performed a meta-analysis of the studies evaluating the concomitant therapy, and of the randomized controlled trials comparing the concomitant and the standard triple therapy.

RESULTS

A meta-analysis of 19 studies (2070 patients) revealed a mean H. pylori cure rate (intention-to-treat) of 88% (95% confidence interval from 85% to 91%) for non-bismuth quadruple therapy. We performed a meta-analysis of the randomized controlled studies comparing the concomitant (481 patients) and the standard triple therapy (503 patients). The former was more effective than the latter: 90% versus 78% (intention-to-treat analysis). Results were homogeneous (I(2) = 0%). The odds ratio for this comparison was 2.36 (95% confidence interval from 1.67 to 3.34). A tendency toward better results with longer treatments (7-10 days versus 3-5 days) has been observed, so it seems reasonable to recommend the length of treatment achieving the highest cure rates (10 days). Clarithromycin resistance may reduce the efficacy of non-bismuth quadruple therapy, although the decrease in eradication rates seems to be far lower than in standard triple therapy. Experience with the non-bismuth quadruple therapy in patients with metronidazole-resistant strains is still very limited.

CONCLUSION

Non-bismuth quadruple (concomitant) therapy appears to be an effective, safe, and well-tolerated alternative to triple therapy and is less complex than sequential therapy. Therefore, this regimen appears well suited for use in settings where the efficacy of triple therapy is unacceptably low.