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Nemr N, Kishk RM, Salem A, Abdalla MO, Abd El-Fadeal NM, Soliman NM. Genotypic detection of metronidazole and clarithromycin resistance in dyspeptic patients with helicobacter pylori. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:41467-41474. [PMID: 35088259 DOI: 10.1007/s11356-021-18198-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/14/2021] [Indexed: 06/14/2023]
Abstract
In Egypt, antibiotic sensitivity analysis for Helicobacter pylori is not routinely performed. We aimed to identify the clarithromycin and metronidazole resistance directly from gastric biopsies for better guide treatment regimens. This cross-sectional descriptive study included 75 adult dyspeptic patients referred to the upper endoscopy unit in Suez Canal University Hospital, Ismailia, Egypt. Gastric biopsies were taken for rapid urease test (RUT) and cultured on brucella agar with antibiotic supplements. Genomic DNA was extracted directly from the specimen, and PCR was performed for direct detection of H. pylori. Also, to explore clarithromycin and metronidazole resistance, mutations in the 23S rRNA gene and the rdxA gene were investigated. We found that 60 samples were positive to RUT (80%), and only 4 samples were positive by culture. UreC gene was detected in 45 specimens. Meanwhile, 26 isolates were contained mutations at positions 2142 and 2143. Amplification of the metronidazole rdx gene was performed by conventional PCR. Out of 45 isolates, DNA sequence analysis of PCR product showed the wild type (ACA) in 9 isolates, while the mutant type (ATA) was detected in 28 isolates. We found a significant proportion of clarithromycin and metronidazole resistance among H. pylori infected patients in our region.
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Affiliation(s)
- Nader Nemr
- Endemic and Infectious Diseases Department, Faculty of Medicine, Suez Canal University, Ismailia, 4155, Egypt
| | - Rania M Kishk
- Medical Microbiology and Immunology Department, Faculty of Medicine, Suez Canal University, Ismailia, 4155, Egypt.
| | - Ayman Salem
- Internal Medicine Department, Faculty of Medicine, Suez Canal University, Ismailia, 4155, Egypt
| | - Mohamed O Abdalla
- Clinical Pathology Department, Faculty of Medicine, Suez Canal University, Ismailia, 4155, Egypt
| | - Noha M Abd El-Fadeal
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Suez Canal University, Ismailia, 4155, Egypt
| | - Nashaat M Soliman
- Endemic and Infectious Diseases Department, Faculty of Medicine, Suez Canal University, Ismailia, 4155, Egypt
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Lok CH, Zhu D, Wang J, Ren YT, Jiang X, Li SJ, Zhao XY. Phenotype and Molecular Detection of Clarithromycin and Levofloxacin Resistance in Helicobacter pylori Clinical Isolates in Beijing. Infect Drug Resist 2020; 13:2145-2153. [PMID: 32753910 PMCID: PMC7352368 DOI: 10.2147/idr.s249370] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/15/2020] [Indexed: 12/12/2022] Open
Abstract
Introduction Understanding drug resistance is important in drug selection for Helicobacter pylori (H. pylori) eradication, and drug resistance data are lacking in Beijing. Purpose This cross-sectional study aimed to isolate H. pylori from patients with gastroduodenal diseases and to analyze drug resistance to clarithromycin (CLA) and levofloxacin (LEV), which are used frequently in China. Patients and Methods One hundred and seventy-six patients with gastroduodenal diseases undergoing gastroduodenoscopy were selected by convenient sampling. Gastric mucosa samples were cultured and sub-cultured using a new medium broth. Active H. pylori strains were confirmed by microscopy observation as Gram-negative curved bacilli with positive test results for urease, oxidase, and catalase, and H. pylori 16S rRNA amplification by polymerase chain reaction (PCR). CLA and LEV resistance was identified by minimum inhibitory concentration (MIC) tests and sequencing of 23S rRNA, gyrA, and gyrB genes. Results From the 176 clinical samples, 112 (112/176, 63.6%) were confirmed with H. pylori infection and 65 (65/176, 36.9%) active H. pylori strains were obtained and further confirmed by MIC assay. Overall, the rates of CLA-resistant and LEV-resistant mutations in the 112 samples were 50.9% and 33.0%, respectively. Mutation related to CLA resistance was A2143G in the 23S rRNA gene and mutations associated with LEV resistance were N87K, D91G, and D91Y in the gyrA gene. Of 112 samples, 22 (19.6%) presented dual resistance to CLA and LEV. Resistance of the H. pylori strains to CLA (r=0.846, P<0.001) and LEV (r=0.936, P<0.001) had a strong correlation in phenotypic and genotypic level. Conclusion The results indicated that resistance of CLA and LEV is severe among patients with gastroduodenitis. A good consistency could be found as to drug resistance between genotypic or phenotypic assay, suggested extending the detection of H. pylori drug resistance from the MIC method to a genotypic assay.
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Affiliation(s)
- Chong-Hou Lok
- Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, People's Republic of China
| | - Dong Zhu
- Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, People's Republic of China
| | - Jia Wang
- Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, People's Republic of China
| | - Yu-Tang Ren
- Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, People's Republic of China
| | - Xuan Jiang
- Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, People's Republic of China
| | - Shu-Jun Li
- Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, People's Republic of China
| | - Xiu-Ying Zhao
- Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, People's Republic of China
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Liu DS, Wang YH, Zhu ZH, Zhang SH, Zhu X, Wan JH, Lu NH, Xie Y. Characteristics of Helicobacter pylori antibiotic resistance: data from four different populations. Antimicrob Resist Infect Control 2019; 8:192. [PMID: 31798838 PMCID: PMC6882003 DOI: 10.1186/s13756-019-0632-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/18/2019] [Indexed: 12/24/2022] Open
Abstract
Aims To describe the characteristics of Helicobacter pylori (H. pylori) antibiotic resistance in clinical isolates from four populations. Methods In total, 1463 H. pylori strains were examined for antibiotic resistance. Among these strains, 804 were isolated from treatment-naïve adults, 133 from previously treated adults, 100 from treatment-naïve children and 426 from a population who participated in a health survey (age ≥ 40 years). The minimum inhibitory concentration was determined by the E-test method. Results In the treatment-naïve adult group, the resistance rates for metronidazole, clarithromycin, levofloxacin, amoxicillin, rifampicin and tetracycline were 78.4, 19.0, 23.3, 1.2, 1.7 and 2.3%, respectively. Compared with this group, the previously treated adult group had significantly higher resistance rates for metronidazole (99.2%), clarithromycin (58.3%) and levofloxacin (52.3%). In addition, the treatment-naïve children had a lower metronidazole resistance rate (46.0%) than the treatment-naïve adults. The resistance rate for clarithromycin was low in treatment-naïve patients with ages ranging from 10 to 24 years. For the strains isolated from the general population group, the resistance rates for metronidazole, clarithromycin, levofloxacin, amoxicillin, rifampicin and tetracycline were 78.6, 10.1, 25.1, 0.5, 2.1 and 0.9%, respectively. Compared with the treatment-naïve adult group, the general population group showed significant differences in clarithromycin resistance. Conclusion The resistance rates for metronidazole, clarithromycin and levofloxacin were high, especially in previously treated adults. Compared to those in treatment-naïve younger patients, the resistance rates for clarithromycin were significantly lower in treatment-naïve patients with ages ranging from 10 to 24 years and in the general population.
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Affiliation(s)
- Dong-Sheng Liu
- 1Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province China
| | - You-Hua Wang
- 1Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province China
| | - Zhen-Hua Zhu
- 1Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province China
| | - Shuang-Hong Zhang
- 1Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province China.,Department of Gastroenterology, Children's Hospital of Jiangxi, Nanchang, Jiangxi Province China
| | - Xuan Zhu
- 1Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province China
| | - Jian-Hua Wan
- 1Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province China
| | - Nong-Hua Lu
- 1Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province China
| | - Yong Xie
- 1Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province China
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Eed EM, Hawash YA, Khalifa AS, Alsharif KF, Alghamdi SA, Saber T, Ismail KA, Shehab-Eldeen SA. Molecular diagnosis of Helicobacter pylori antibiotic resistance in the Taif region, Saudi Arabia. Microbiol Immunol 2019; 63:199-205. [PMID: 31045263 DOI: 10.1111/1348-0421.12686] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 04/28/2019] [Indexed: 12/13/2022]
Abstract
Success in eradication of Helicobacter pylori is declining globally because H. pylori has developed resistance against most of the antibiotics proposed for eradication regimens, mainly through point mutations. The present study included 200 patients with dyspepsia attending Taif Hospital. Gastric biopsies were obtained during gastroscopy and subjected to rapid urease testing. Molecular methods were used to confirm diagnoses of H. pylori infection and to identify resistance gene variants of four antibiotics; namely, clarithromycin, metronidazole, fluoroquinolones and tetracycline (23S rRNA, gyrA, rdxA and 16S rRNA respectively). Of all investigated patients, Molecular diagnoses were made in 143 of all investigated patients; thus, the prevalence was .5%. The overall rate of resistance to clarithromycin among the H. pylori-positive patients was high (39.9%) and the rate of resistance significantly greater (48.2%) among the secondary resistance group, secondary resistance being defined as resistance as a result of previous exposure to the relevant antibiotic. The rate of resistance to fluoroquinolones was considered moderate; the difference in rate of resistance between the primary and secondary resistance groups (8.4% and 9.5%, respectively) was not significant Also, there was a low prevalence of both primary and the secondary tetracycline resistance in the study cohort. In contrast, the prevalence of metronidazole resistance was considered high with no significant difference between the two resistance groups. H. pylori showed an increased prevalence of resistance to all four of the commonly used therapeutic agents. Thus, eradication therapy should be based on the regional results of susceptibility testing. Moreover, treatment tailored according to individually determined H. pylori susceptibility may be a reasonable future goal.
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Affiliation(s)
- Emad M Eed
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia.,Medical Microbiology and Immunology Department, Faculty of Medicine, Menoufia University, Al Menoufia, Egypt
| | - Yousry A Hawash
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia.,Molecular and Clinical Parasitology Department, National Liver Institute, Menoufia University, Al Menoufia, Egypt
| | - Amany S Khalifa
- Clinical Pathology Department, Faculty of Medicine, Menoufia University, Al Menoufia, Egypt.,Medical Microbiology and Immunology Department, Faculty of Pharmacy, Taif University, Taif, Saudi Arabia
| | - Khalaf F Alsharif
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia
| | - Saleh A Alghamdi
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia
| | - Taisir Saber
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia.,Medical Microbiology and Immunology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Khadiga A Ismail
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia.,Department of Parasitology, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Somaia A Shehab-Eldeen
- Tropical Medicine Department, Faculty of Medicine, Menoufia University, Al Menoufia, Egypt
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5
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Güven B, Gülerman F, Kaçmaz B. Helicobacter pylori resistance to clarithromycin and fluoroquinolones in a pediatric population in Turkey: A cross-sectional study. Helicobacter 2019; 24:e12581. [PMID: 30950125 DOI: 10.1111/hel.12581] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 02/23/2019] [Accepted: 02/27/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Helicobacter pylori antimicrobial resistance is gradually increasing around the world. However, there are a limited number of studies reporting on this issue in the pediatric population. In this study, we aimed to determine H pylori resistance to clarithromycin and fluoroquinolones in the pediatric patients living in Kırıkkale province that were detected with H pylori in gastric biopsies. Moreover, we also aimed to investigate the concordance between the histopathologic and molecular methods used in the diagnosis of H pylori infection. MATERIALS AND METHODS Patients aged 2-18 years who had a history of epigastric pain and/or nausea persisting for longer than 1 month underwent upper gastrointestinal endoscopy. Biopsies were taken from the gastric antral mucosa. In the samples detected with H pylori in the histopathologic examination, the presence of H pylori and H pylori resistance to clarithromycin and fluoroquinolones was investigated using the GenoType HelicoDR test which allows the detection of wild-type and mutant genes. The strains detected with more than one mutant gene are defined as hetero-resistant strains. RESULTS The 93 patients that underwent DNA extraction and amplification included 68 (73.1%) girls and 25 (26.9%) boys with a median age of 15 ± 2.62 (range 6-17) years. The overall concordance for the diagnosis of H pylori infection between histopathology and PCR was 94%, and H pylori resistance to clarithromycin and fluoroquinolones was 27% and 15%, respectively. CONCLUSIONS The high H pylori resistance to clarithromycin and fluoroquinolones among the pediatric patients in our region implicates that the antibiotic sensitivity of strains should be studied prior to administration in accordance with the recommendations provided in the guidelines. Moreover, the presence of hetero-resistant strains in our patients may be a reason for treatment failure.
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Affiliation(s)
- Burcu Güven
- Pediatric Gastroenterology Department, Yüzüncü Yıl University Medical School, Van, Turkey
| | - Fulya Gülerman
- Pediatric Gastroenterology Department, Kırıkkale University Medical School, Kırıkkale, Turkey
| | - Birgül Kaçmaz
- Infectious Diseases & Clinical Microbiology Department, Kırıkkale University Medical School, Kırıkkale, Turkey
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6
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Lopo I, Libânio D, Pita I, Dinis-Ribeiro M, Pimentel-Nunes P. Helicobacter pylori antibiotic resistance in Portugal: Systematic review and meta-analysis. Helicobacter 2018; 23:e12493. [PMID: 29911329 DOI: 10.1111/hel.12493] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Portugal presents both a high prevalence of Helicobacter pylori (Hp) infection and a high prevalence of antibiotic resistance. However, conclusive data on its magnitude are lacking. We aimed at summarizing the existing data. MATERIALS AND METHODS A systematic review was conducted after searching in two databases (PubMed and SciELO). Meta-analysis was performed, and comparison of resistance rates between children and adults and by type of resistance (primary and secondary) was made. RESULTS Eight cross-sectional studies assessing Hp resistance to antibiotics were included. Overall resistance rates were as follows: clarithromycin (CLA) 42% (95% CI: 30-54), metronidazole (MTZ) 25% (95% CI: 15-38), ciprofloxacin (CIP) 9% (95% CI: 3-18), levofloxacin (LVX) 18% (95% CI: 2-42), tetracycline (TTC) 0.2% (95% CI: 0-1), and amoxicillin (AMX) 0.1% (95% CI: 0-0.2). Multidrug resistance was also an important problem, with the following global resistance rates: CLA plus MTZ of 10% (adults 20% (95% CI: 15-26) vs children 6% (95% CI: 4-9)) and CLA plus CIP of 2% (primary resistance in children's group). High secondary resistance rates were found for all antibiotics. Resistance was higher among adults for all antibiotics, except CLA that had high resistance levels both among adults and children (42% 95% CI: 14-71 and 40% 95% CI: 33-47). CONCLUSIONS Hp resistance to the most widely used antibiotics is high in Portugal. Accordingly, our results suggest that the best therapeutic strategy for Hp in Portugal may be quadruple therapy with bismuth for adults and triple therapy including AMX plus MTZ or bismuth-based therapy for children.
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Affiliation(s)
- Inês Lopo
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Diogo Libânio
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Inês Pita
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Mário Dinis-Ribeiro
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Pedro Pimentel-Nunes
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal.,Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.,Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
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7
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Kubra Hussaini SZ, Humaira Hussaini SZ, Yasmeen R, Unnisa B, Syed AAA, Khan MN, Hassan SI. Comparison of efficacy and pharmacoeconomics of two Helicobacter pylori eradication regimens in peptic ulcer disease. Perspect Clin Res 2018; 9:4-8. [PMID: 29430411 PMCID: PMC5799951 DOI: 10.4103/picr.picr_99_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Helicobacter pylori, the cause of most peptic ulcer diseases, infects approximately 50% of the population worldwide. Indian data on cost and effectiveness of the standard first-line therapies for H. pylori eradication are scarce. Thus, the present study was aimed at comparing the cost and efficacy of two standard first-line therapies: Regimen I comprising pantoprazole (40 mg) plus amoxicillin (750 mg) plus clarithromycin (500 mg) (PAC) and Regimen II comprising rabeprazole (20 mg) plus amoxicillin (625 mg) plus metronidazole (200 mg) (RAM). Methodology This prospective, observational, bottom-up study collected demographic, economic, diagnostic, and therapeutic data from 60 H. pylori-positive patients. The study was carried out for 6 months in the Gastroenterology Department of a Tertiary Care Hospital in Hyderabad, Telangana, India. Results Health-care system perspective was used to account for direct costs. Average cost per patient for complete H. pylori eradication was Rs. 10,221 and Rs. 8568 for Regimen I and Regimen II, respectively. Inpatient cost was considerably higher than the outpatient cost. Diagnostic costs ranked first in direct costs, followed by hospitalization costs, medication costs, and finally, physician's office visit cost. Individual patient's costs difference between two regimens was found to be statistically significant. Overall, Regimen I proved to be more efficacious than Regimen II, but Regimen II proved to be more cost-effective than Regimen I. Furthermore, incremental cost-effectiveness analysis revealed additional cost of Rs. 127 per patient if the patient was treated with Regimen I instead of Regimen II. Conclusion Our study showed that Regimen II (RAM) was more cost-effective than Regimen I (PAC), but PAC achieved faster H. pylori eradication than RAM. We assume that this study provides local clinical data as to which regimen may be useful in a particular patient. National Level Clinical Trials are required to further ascertain this conclusion.
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Affiliation(s)
| | | | - Ruheena Yasmeen
- PharmD Intern, Deccan School of Pharmacy, Hyderabad, Telangana, India
| | - Bader Unnisa
- PharmD Intern, Deccan School of Pharmacy, Hyderabad, Telangana, India
| | - Aamir Ali Asgar Syed
- Department of Pharmacy Practice, Deccan School of Pharmacy, Hyderabad, Telangana, India
| | - Md Nematullah Khan
- Department of Pharmacy Practice, Deccan School of Pharmacy, Hyderabad, Telangana, India
| | - Syed Ibrahim Hassan
- Department of Gastroenterology, Princess Esra Hospital, Deccan College of Medical Sciences, Hyderabad, Telangana, India
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8
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Mascellino MT, Porowska B, De Angelis M, Oliva A. Antibiotic susceptibility, heteroresistance, and updated treatment strategies in Helicobacter pylori infection. Drug Des Devel Ther 2017; 11:2209-2220. [PMID: 28814829 PMCID: PMC5546184 DOI: 10.2147/dddt.s136240] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
In this review, we discuss the problem of antibiotic resistance, heteroresistance, the utility of cultures and antibiotic susceptibility tests in Helicobacter pylori (Hp) eradication, as well as the updated treatment strategies for this infection. The prevalence of antibiotic resistance is increasing all over the world, especially for metronidazole and clarithromycin, because of their heavy use in some geographical areas. Heteroresistance (simultaneous presence of both susceptible and resistant strains in different sites of a single stomach) is another important issue, as an isolate could be mistakenly considered susceptible if a single biopsy is used for antimicrobial tests. We also examined literature data regarding eradication success rates of culture-guided and empiric therapies. The empiric therapy and the one based on susceptibility testing, in Hp eradication, may depend on several factors such as concomitant diseases, the number of previous antibiotic treatments, differences in bacterial virulence in individuals with positive or negative cultures, together with local antibiotic resistance patterns in real-world settings. Updated treatment strategies in Hp infection presented in the guidelines of the Toronto Consensus Group (2016) are reported. These suggest to prolong eradication therapy up to 14 days, replacing the old triple therapy with a quadruple therapy based on proton pump inhibitor (PPI), bismuth, metronidazole, and tetracycline for most of the patients, or as an alternative quadruple therapy without bismuth, based on the use of PPI, amoxicillin, metronidazole, and clarithromycin. The new drug vonoprazan, a first-in-class potassium-competitive acid blocker recently approved in Japan, is also considered to be a promising solution for Hp eradication, even for clarithromycin-resistant strains. Furthermore, there is growing interest in finding new therapeutic strategies, such as the development of vaccines or the use of natural resources, including probiotics, plants, or nutraceuticals.
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Affiliation(s)
| | - Barbara Porowska
- Department of Cardio-Thoracic, Vascular, General Surgery and of Organ Transplants, Policlinico Umberto I, Rome, Italy
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9
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Di Giulio M, Di Campli E, Di Bartolomeo S, Cataldi V, Marzio L, Grossi L, Ciccaglione AF, Nostro A, Cellini L. In vitro antimicrobial susceptibility of Helicobacter pylori to nine antibiotics currently used in Central Italy. Scand J Gastroenterol 2016; 51:263-9. [PMID: 26554617 DOI: 10.3109/00365521.2015.1092577] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Helicobacter pylori expresses an increased resistance in respect to antimicrobials currently used in therapy. The aim of this study was to evaluate the antimicrobial profiles of H. pylori isolates to nine conventional antibiotics used in a Central Region (Abruzzo) of Italy. MATERIALS AND METHODS Biopsies were taken from antrum and fundus of 112 adult and 3 children with Urea Breath Test positive with dyspeptic symptoms and analyzed for H. pylori culture and antibacterial activity. Antimicrobial susceptibility tests were performed for clarithromycin, metronidazole, levofloxacin, moxifloxacin, ciprofloxacin, tetracycline, amoxicillin, ampicillin, and rifabutin by a modified agar dilution susceptibility test. RESULTS Bacterial culture was successful in 100 out of 115 patients. Helicobacter pylori strains were isolated from 98 antrum and 83 fundus samples. The rate of recovery of H. pylori strains was 90.50% (181/200). The percentages of resistance were as follows: clarithromycin 72.44% antrum, 72.28% fundus; metronidazole 34.69% antrum, 42.16% fundus; levofloxacin 42.85% antrum, 53.01% fundus; moxifloxacin 37.35% antrum, 46.57% fundus; ciprofloxacin 39.47% antrum, 44.28% fundus; tetracycline 2.63% antrum, 2.85% fundus; amoxicillin 1.02% antrum, 1.20% fundus; ampicillin 0% antrum and fundus and rifabutin 0% antrum, 1.20% fundus. A total of 35 subjects harbored multi-resistant strains. CONCLUSIONS This study underlines the high rate of resistance to clarithromycin, metronidazole and quinolones, which may reflect an overuse of them. Culture and susceptibility test, should be performed to prevent the emergence of multi-resistance and to assess an efficacious regimen.
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Affiliation(s)
- Mara Di Giulio
- a Department of Pharmacy , University "G. d'Annunzio" Chieti-Pescara , Chieti , Italy
| | - Emanuela Di Campli
- a Department of Pharmacy , University "G. d'Annunzio" Chieti-Pescara , Chieti , Italy
| | - Soraya Di Bartolomeo
- a Department of Pharmacy , University "G. d'Annunzio" Chieti-Pescara , Chieti , Italy
| | - Valentina Cataldi
- a Department of Pharmacy , University "G. d'Annunzio" Chieti-Pescara , Chieti , Italy
| | - Leonardo Marzio
- b Digestive Physiopathology Unit, University "G. d'Annunzio" Chieti-Pescara, Pescara Civic Hospital , Italy
| | - Laurino Grossi
- b Digestive Physiopathology Unit, University "G. d'Annunzio" Chieti-Pescara, Pescara Civic Hospital , Italy
| | | | - Antonia Nostro
- c Department of Pharmaceutical Sciences and Health Products , University of Messina , Messina , Italy
| | - Luigina Cellini
- a Department of Pharmacy , University "G. d'Annunzio" Chieti-Pescara , Chieti , Italy
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10
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Thung I, Aramin H, Vavinskaya V, Gupta S, Park JY, Crowe SE, Valasek MA. Review article: the global emergence of Helicobacter pylori antibiotic resistance. Aliment Pharmacol Ther 2016; 43:514-33. [PMID: 26694080 PMCID: PMC5064663 DOI: 10.1111/apt.13497] [Citation(s) in RCA: 486] [Impact Index Per Article: 60.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 05/04/2015] [Accepted: 11/19/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Helicobacter pylori is one of the most prevalent global pathogens and can lead to gastrointestinal disease including peptic ulcers, gastric marginal zone lymphoma and gastric carcinoma. AIM To review recent trends in H. pylori antibiotic resistance rates, and to discuss diagnostics and treatment paradigms. METHODS A PubMed literature search using the following keywords: Helicobacter pylori, antibiotic resistance, clarithromycin, levofloxacin, metronidazole, prevalence, susceptibility testing. RESULTS The prevalence of bacterial antibiotic resistance is regionally variable and appears to be markedly increasing with time in many countries. Concordantly, the antimicrobial eradication rate of H. pylori has been declining globally. In particular, clarithromycin resistance has been rapidly increasing in many countries over the past decade, with rates as high as approximately 30% in Japan and Italy, 50% in China and 40% in Turkey; whereas resistance rates are much lower in Sweden and Taiwan, at approximately 15%; there are limited data in the USA. Other antibiotics show similar trends, although less pronounced. CONCLUSIONS Since the choice of empiric therapies should be predicated on accurate information regarding antibiotic resistance rates, there is a critical need for determination of current rates at a local scale, and perhaps in individual patients. Such information would not only guide selection of appropriate empiric antibiotic therapy but also inform the development of better methods to identify H. pylori antibiotic resistance at diagnosis. Patient-specific tailoring of effective antibiotic treatment strategies may lead to reduced treatment failures and less antibiotic resistance.
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Affiliation(s)
- I. Thung
- Division of Anatomic PathologyDepartment of PathologyUniversity of California San Diego Medical CenterSan DiegoCAUSA
| | - H. Aramin
- Division of Anatomic PathologyDepartment of PathologyUniversity of California San Diego Medical CenterSan DiegoCAUSA
| | - V. Vavinskaya
- Division of Anatomic PathologyDepartment of PathologyUniversity of California San Diego Medical CenterSan DiegoCAUSA
| | - S. Gupta
- Division of GastroenterologyDepartment of MedicineUniversity of California San Diego Medical CenterLa JollaCAUSA
| | - J. Y. Park
- Department of Pathology and the Eugene McDermott Center for Human Growth and DevelopmentUniversity of Texas Southwestern Medical Center and Children's Medical CenterDallasTXUSA
| | - S. E. Crowe
- Division of GastroenterologyDepartment of MedicineUniversity of California San Diego Medical CenterLa JollaCAUSA
| | - M. A. Valasek
- Division of Anatomic PathologyDepartment of PathologyUniversity of California San Diego Medical CenterSan DiegoCAUSA
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11
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Almeida N, Donato MM, Romãozinho JM, Luxo C, Cardoso O, Cipriano MA, Marinho C, Fernandes A, Calhau C, Sofia C. Beyond Maastricht IV: are standard empiric triple therapies for Helicobacter pylori still useful in a South-European country? BMC Gastroenterol 2015; 15:23. [PMID: 25886722 PMCID: PMC4339300 DOI: 10.1186/s12876-015-0245-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 02/02/2015] [Indexed: 01/10/2023] Open
Abstract
Background Empiric triple treatments for Helicobacter pylori (H. pylori) are increasingly unsuccessful. We evaluated factors associated with failure of these treatments in the central region of Portugal. Methods This single-center, prospective study included 154 patients with positive 13C-urea breath test (UBT). Patients with no previous H. pylori treatments (Group A, n = 103) received pantoprazole 40 mg 2×/day, amoxicillin 1000 mg 12/12 h and clarithromycin (CLARI) 500 mg 12/12 h, for 14 days. Patients with previous failed treatments (Group B, n = 51) and no history of levofloxacin (LVX) consumption were prescribed pantoprazole 40 mg 2×/day, amoxicillin 1000 mg 12/12 h and LVX 250 mg 12/12 h, for 10 days. H. pylori eradication was assessed by UBT 6–10 weeks after treatment. Compliance and adverse events were assessed by verbal and written questionnaires. Risk factors for eradication failure were determined by multivariate analysis. Results Intention-to-treat and per-protocol eradication rates were Group A: 68.9% (95% CI: 59.4–77.1%) and 68.8% (95% CI: 58.9–77.2%); Group B: 52.9% (95% CI: 39.5–66%) and 55.1% (95% CI: 41.3–68.2%), with 43.7% of Group A and 31.4% of Group B reporting adverse events. Main risk factors for failure were H. pylori resistance to CLARI and LVX in Groups A and B, respectively. Another independent risk factor in Group A was history of frequent infections (OR = 4.24; 95% CI 1.04–17.24). For patients with no H. pylori resistance to CLARI, a history of frequent infections (OR = 4.76; 95% CI 1.24–18.27) and active tobacco consumption (OR = 5.25; 95% CI 1.22–22.69) were also associated with eradication failure. Conclusions Empiric first and second-line triple treatments have unacceptable eradication rates in the central region of Portugal and cannot be used, according to Maastricht recommendations. Even for cases with no H. pylori resistance to the used antibiotics, results were unacceptable and, at least for CLARI, are influenced by history of frequent infections and tobacco consumption.
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Affiliation(s)
- Nuno Almeida
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto e Avenida Bissaya Barreto, 3000-075, Coimbra, Portugal.
| | - Maria Manuel Donato
- Gastroenterology Centre, Faculty of Medicine, Coimbra University, Praceta Mota Pinto e Avenida Bissaya Barreto, 3000-075, Coimbra, Portugal.
| | - José Manuel Romãozinho
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto e Avenida Bissaya Barreto, 3000-075, Coimbra, Portugal. .,Gastroenterology Centre, Faculty of Medicine, Coimbra University, Praceta Mota Pinto e Avenida Bissaya Barreto, 3000-075, Coimbra, Portugal.
| | - Cristina Luxo
- Laboratory of Microbiology, Faculty of Pharmacy, Coimbra University, Azinhaga de Santa Comba, 3000-548, Coimbra, Portugal.
| | - Olga Cardoso
- Laboratory of Microbiology, Faculty of Pharmacy, Coimbra University, Azinhaga de Santa Comba, 3000-548, Coimbra, Portugal.
| | - Maria Augusta Cipriano
- Pathology Department, Coimbra University Hospital Centre, Praceta Mota Pinto e Avenida Bissaya Barreto, 3000-075, Coimbra, Portugal.
| | - Carol Marinho
- Pathology Department, Coimbra University Hospital Centre, Praceta Mota Pinto e Avenida Bissaya Barreto, 3000-075, Coimbra, Portugal.
| | - Alexandra Fernandes
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto e Avenida Bissaya Barreto, 3000-075, Coimbra, Portugal.
| | - Carlos Calhau
- Gastroenterology Centre, Faculty of Medicine, Coimbra University, Praceta Mota Pinto e Avenida Bissaya Barreto, 3000-075, Coimbra, Portugal.
| | - Carlos Sofia
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Praceta Mota Pinto e Avenida Bissaya Barreto, 3000-075, Coimbra, Portugal. .,Gastroenterology Centre, Faculty of Medicine, Coimbra University, Praceta Mota Pinto e Avenida Bissaya Barreto, 3000-075, Coimbra, Portugal.
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12
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Trends in secondary antibiotic resistance of Helicobacter pylori from 2007 to 2014: has the tide turned? J Clin Microbiol 2014; 53:522-7. [PMID: 25428158 DOI: 10.1128/jcm.03001-14] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The current guidelines recommend culture and antibiotic susceptibility testing of Helicobacter pylori following two failed eradication attempts. Where testing is unavailable, epidemiological data for secondary H. pylori resistance are essential to allow for the rational use of antibiotics. The aim of this study was to describe the temporal changes in antibiotic resistance among adults previously treated for H. pylori infections and to identify predictors of resistance. Between 2007 and 2014, consecutive patients undergoing gastroscopy with H. pylori culture and susceptibility testing at our institution following at least two treatment failures were retrospectively identified. Antibiotic susceptibilities were recorded and linked to the demographic data. A total of 1,042 patients were identified, including 739 (70.9%) males, aged 39.3 ± 18.9 years. Resistance to clarithromycin, metronidazole, and levofloxacin was found in 57.2%, 64.4%, and 5.1% of isolates, respectively. Dual resistance to clarithromycin and metronidazole was seen in 39.9%. Over the study period, clarithromycin resistance increased annually in a linear manner (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.03 to 1.14; P < 0.01), levofloxacin resistance decreased annually (OR, 0.78; 95% CI, 0.61 to 0.92; P < 0.01), and metronidazole resistance was nonlinear. Age was an independent predictor of resistance to all antibiotics. Time elapsed predicted resistance for clarithromycin and levofloxacin and dual resistance for clarithromycin-metronidazole. Secondary resistance of H. pylori to clarithromycin and metronidazole remains high. The low secondary resistance to levofloxacin makes it an attractive treatment option in our region for patients following two failed eradication attempts.
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13
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Picoli SU, Mazzoleni LE, Fernández H, De Bona LR, Neuhauss E, Longo L, Prolla JC. Resistance to amoxicillin, clarithromycin and ciprofloxacin of Helicobacter pylori isolated from Southern Brazil patients. Rev Inst Med Trop Sao Paulo 2014; 56:197-200. [PMID: 24878996 PMCID: PMC4085860 DOI: 10.1590/s0036-46652014000300003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 10/17/2013] [Indexed: 01/14/2023] Open
Abstract
Introduction:Helicobacter pylori is a bacteria which infects half the world
population and is an important cause of gastric cancer. The eradication therapy is
not always effective because resistance to antimicrobials may occur. The aim of this
study was to determine the susceptibility profile of H. pylori to
amoxicillin, clarithromycin and ciprofloxacin in the population of Southern
Brazil. Material and methods: Fifty four samples of H. pylori
were evaluated. The antibiotics susceptibility was determined according to the
guidelines of the British Society for Antimicrobial Chemotherapy and the Comité de
l'Antibiogramme de la Société Française de Microbiologie. Results: Six (11.1%) H. pylori isolates were resistant
to clarithromycin, one (1.9%) to amoxicillin and three (5.5%) to ciprofloxacin. These
indices of resistance are considered satisfactory and show that all of these
antibiotics can be used in the empirical therapy. Conclusion: The antibiotics amoxicillin and clarithromycin are still a
good option for first line anti-H. pylori treatment in the
population of Southern Brazil.
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Affiliation(s)
| | | | - Heriberto Fernández
- Institute of Clinical Microbiology, School of Medicine, Universidad Austral de Chile, Valdivia, Chile
| | - Laura Renata De Bona
- Hospital de Clínicas de Porto Alegre, Service of Gastroenterology, Porto Alegre, RS, Brazil
| | - Erli Neuhauss
- Centro Universitário Metodista, Porto Alegre, RS, Brazil
| | - Larisse Longo
- Hospital de Clínicas de Porto Alegre, Service of Gastroenterology, Porto Alegre, RS, Brazil
| | - João Carlos Prolla
- Programa de Pós-Graduação em Gastroenterologia e Hepatologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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14
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Almeida N, Romãozinho JM, Donato MM, Luxo C, Cardoso O, Cipriano MA, Marinho C, Fernandes A, Calhau C, Sofia C. Helicobacter pylori antimicrobial resistance rates in the central region of Portugal. Clin Microbiol Infect 2014; 20:1127-33. [PMID: 24890952 DOI: 10.1111/1469-0691.12701] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Revised: 05/25/2014] [Accepted: 05/27/2014] [Indexed: 12/11/2022]
Abstract
Helicobacter pylori resistance to antimicrobial agents is steadily increasing. It is extremely important to be aware of the local prevalence of antibiotic resistance so as to adjust treatment strategies. During this single-centre, prospective study, we aimed to determine primary and secondary resistance rates of H. pylori to antibiotics as well as host and bacterial factors associated with this problem. Overall, 180 patients (131 female; mean age 43.4±13.5 years; primary resistance 103; secondary resistance 77) with positive (13) C-urea breath test were submitted to upper endoscopy with gastric biopsies. Helicobacter pylori was cultured and antimicrobial susceptibility was determined by Etest and molecular methods. Clinical and microbiological characteristics associated with resistance were evaluated by logistic regression analysis. Among the 180 isolates 50% were resistant to clarithromycin (primary 21.4%; secondary 88.3%), 34.4% to metronidazole (primary 29.1%; secondary 41.6%), 33.9% to levofloxacin (primary 26.2%; secondary 44.2%), 0.6% to tetracycline and 0.6% to amoxicillin. Being female was an independent predictor of resistance to clarithromycin and metronidazole. Previous, failed, eradication treatments were also associated with a decrease in susceptibility to clarithromycin. History of frequent infections, first-degree relatives with gastric carcinoma and low education levels determined increased resistance to levofloxacin. Mutations in the 23S rRNA and gyrA genes were frequently found in isolates with resistance to clarithromycin and levofloxacin, respectively. This study revealed that resistance rates to clarithromycin, metronidazole and levofloxacin are very high and may compromise H. pylori eradication with first-line and second-line empiric triple treatments in Portugal.
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Affiliation(s)
- N Almeida
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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15
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Song M, Ang TL. Second and third line treatment options for Helicobacter pylori eradication. World J Gastroenterol 2014; 20:1517-1528. [PMID: 24587627 PMCID: PMC3925860 DOI: 10.3748/wjg.v20.i6.1517] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 10/29/2013] [Accepted: 01/06/2014] [Indexed: 02/06/2023] Open
Abstract
Helicobacter pylori is a highly successful bacterium with a high global prevalence and the infection carries significant disease burden. It is also becoming increasingly difficult to eradicate and the main reason for this is growing primary antibiotic resistance rates in a world where antibiotics are frequently prescribed and readily available. Despite knowing much more about the bacterium since its discovery, such as its genomic makeup and pathogenesis, we have seen declining treatment success. Therefore, clinicians today must be prepared to face one, two or even multiple treatment failures, and should be equipped with sufficient knowledge to decide on the appropriate salvage therapy when this happens. This article discusses the factors contributing to treatment failure and reviews the second and third-line treatment strategies that have been investigated. Established empiric second line treatment options include both bismuth based quadruple therapy and levofloxacin based triple therapy. Antibiotic testing is recommended prior to initiating third line treatment. In the event that antibiotic susceptibility testing is unavailable, third line treatment options include rifabutin, rifaximin and sitafloxacin based therapies.
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16
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Wu TS, Hu HM, Kuo FC, Kuo CH. Eradication of Helicobacter pylori infection. Kaohsiung J Med Sci 2013; 30:167-72. [PMID: 24656156 DOI: 10.1016/j.kjms.2013.11.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 06/28/2013] [Indexed: 01/10/2023] Open
Abstract
Eradication of Helicobacter pylori infection has become an important issue recently, because this bacterial species cluster can cause many gastrointestinal diseases. Elevated antibiotic resistance is related to an increasing failure rate of H. pylori eradication. Standard triple therapy is still the first-line therapy; however, according to the Maastricht IV Consensus Report, it should be abandoned in areas of high clarithromycin resistance. Alternative first-line therapies include bismuth-containing quadruple therapy, sequential, concomitant, and hybrid therapies. Quinolone-based triple therapy may be considered as first-line therapy in areas of clarithromycin resistance >15-20% and quinolone resistance <10%. Unique second-line therapy is still unclear, and bismuth-containing quadruple therapy or levofloxacin-based triple therapy can be used as rescue treatment. Third-line therapy should be under culture guidance to select the most effective regimens (such as levofloxacin-based, rifabutin-based, or furazolidone-based therapies). Antibiotics resistance, patient compliance, and CYP 2C19 genotypes could influence the outcome. Clinicians should use antibiotics according to local reports.
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Affiliation(s)
- Tzung-Shiun Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Huang-Ming Hu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Fu-Chen Kuo
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chao-Hung Kuo
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Cancer Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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17
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Tay CY, Windsor HM, Thirriot F, Lu W, Conway C, Perkins TT, Marshall BJ. Helicobacter pylori eradication in Western Australia using novel quadruple therapy combinations. Aliment Pharmacol Ther 2012; 36:1076-83. [PMID: 23072648 DOI: 10.1111/apt.12089] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 06/05/2012] [Accepted: 09/26/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Helicobacter pylori eradication rates with standard triple therapy are declining worldwide. The optimal management of H. pylori is evolving and new treatment combinations for antibiotic resistant H. pylori strains are required, especially for patients with penicillin allergy. AIM To review the effectiveness of alternative antibiotic combinations and necessity of pre-antibiotic sensitivity testing. METHODS A total of 310 consecutive patients who had failed at least one course of standard 7-day triple therapy initially prescribed by their physicians were included in this study between year 2007 and 2011. Antibiotics were prescribed based on pre-antibiotic sensitivity tests and, if any, patient's allergy to penicillin. RESULTS In 98.7% of the patients' samples, H. pylori was successfully cultured. The proportion resistant to clarithromycin and metronidazole was 94.1% and 67.6% respectively, with 65% resistant to both. For the in-house primary quadruple therapy, with Proton pump inhibitor, Amoxicillin, Rifabutin and Ciprofloxacin (PARC), H. pylori was successfully eradicated in 95.2% of patients. For patients allergic to amoxicillin, an alternative quadruple therapy using Proton pump inhibitor, Bismuth subcitrate, Rifabutin and Ciprofloxacin (PBRC) gave an eradication rate of 94.2%. Patients needing alternative salvage therapy were given novel personalised combinations consisting of bismuth, rifabutin, tetracycline or furazolidone; the eradication rate was 73.8%. CONCLUSIONS Patients who present with antibiotic resistant H. pylori can be confidently treated with PARC, PBRC or other personalised salvage therapies. These regimens can be used when treatment options are limited by penicillin allergy. Pre-treatment H. pylori antibiotic sensitivity tests contributed to the high eradication rate in this study.
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Affiliation(s)
- C Y Tay
- School of Pathology and Laboratory Medicine M502, University of Western Australia, Nedlands, WA, Australia.
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18
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Caro SD, Fini L, Daoud Y, Grizzi F, Gasbarrini A, Lorenzo AD, Renzo LD, McCartney S, Bloom S. Levofloxacin/amoxicillin-based schemes vs quadruple therapy for Helicobacter pylori eradication in second-line. World J Gastroenterol 2012; 18:5669-78. [PMID: 23155306 PMCID: PMC3484334 DOI: 10.3748/wjg.v18.i40.5669] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2012] [Revised: 05/29/2012] [Accepted: 06/08/2012] [Indexed: 02/06/2023] Open
Abstract
Worldwide prevalence of Helicobacter pylori (H. pylori) infection is approximately 50%, with the highest being in developing countries. We compared cure rates and tolerability (SE) of second-line anti-H. pylori levofloxacin/amoxicillin (LA)-based triple regimens vs standard quadruple therapy (QT). An English language literature search was performed up to October 2010. A meta-analysis was performed including randomized clinical trials comparing 7- or 10-d LA with 7-d QT. In total, 10 articles and four abstracts were identified. Overall eradication rate in LA was 76.5% (95% CI: 64.4%-97.6%). When only 7-d regimens were included, cure rate was 70.6% (95% CI: 40.2%-99.1%), whereas for 10-d combinations, cure rate was significantly higher (88.7%; 95% CI: 56.1%-109.9%; P < 0.05). Main eradication rate for QT was 67.4% (95% CI: 49.7%-67.9%). The 7-d LA and QT showed comparable efficacy [odds ratio (OR): 1.09; 95% CI: 0.63-1.87], whereas the 10-d LA regimen was significantly more effective than QT (OR: 5.05; 95% CI: 2.74-9.31; P < 0.001; I2 = 75%). No differences were reported in QT eradication rates among Asian and European studies, whereas LA regimens were more effective in European populations (78.3% vs 67.7%; P = 0.05). Incidence of SE was lower in LA therapy than QT (OR: 0.39; 95% CI: 0.18-0.85; P = 0.02). A higher rate of side effects was reported in Asian patients who received QT. Our findings support the use of 10-d LA as a simple second-line treatment for H. pylori eradication with an excellent eradication rate and tolerability. The optimal second-line alternative scheme might differ among countries depending on quinolone resistance.
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Cerqueira RM, Correia MR, Fernandes CD, Vilar H, Manso MC. Cumulative Helicobacter pylori Eradication Therapy in Obese Patients Undergoing Gastric Bypass Surgery. Obes Surg 2012; 23:145-9. [DOI: 10.1007/s11695-012-0747-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Kuo CH, Kuo FC, Hu HM, Liu CJ, Wang SSW, Chen YH, Hsieh MC, Hou MF, Wu DC. The Optimal First-Line Therapy of Helicobacter pylori Infection in Year 2012. Gastroenterol Res Pract 2012; 2012:168361. [PMID: 22792095 PMCID: PMC3390052 DOI: 10.1155/2012/168361] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 04/17/2012] [Indexed: 02/08/2023] Open
Abstract
This paper reviews the literature about first-line therapies for H. pylori infection in recent years. First-line therapies are facing a challenge because of increasing treatment failure due to elevated antibiotics resistance. Several new treatment strategies that recently emerged to overcome antibiotic resistance have been surveyed. Alternative first-line therapies include bismuth-containing quadruple therapy, sequential therapy, concomitant therapy, and hybrid therapy. Levofloxacin-based therapy shows impressive efficacy but might be employed as rescue treatment due to rapidly raising resistance. Rifabutin-based therapy is also regarded as a rescue therapy. Several factors including antibiotics resistance, patient compliance, and CYP 2C19 genotypes could influence the outcome. Clinicians should use antibiotics according to local reports. It is recommended that triple therapy should not be used in areas with high clarithromycin resistance or dual clarithromycin and metronidazole resistance.
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Affiliation(s)
- Chao-Hung Kuo
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung City 807, Taiwan
- Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City 807, Taiwan
- Cancer Center, Kaohsiung Medical University Hospital, Kaohsiung City 807, Taiwan
| | - Fu-Chen Kuo
- Department of Health Management, I-Shou University, E-Da Hospital, Kaohsiung County 824, Taiwan
- Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung City 807, Taiwan
| | - Huang-Ming Hu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung City 807, Taiwan
- Cancer Center, Kaohsiung Medical University Hospital, Kaohsiung City 807, Taiwan
| | - Chung-Jung Liu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung City 807, Taiwan
- Cancer Center, Kaohsiung Medical University Hospital, Kaohsiung City 807, Taiwan
| | - Sophie S. W. Wang
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung City 807, Taiwan
- Cancer Center, Kaohsiung Medical University Hospital, Kaohsiung City 807, Taiwan
| | - Yen-Hsu Chen
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung City 807, Taiwan
| | - Ming-Chia Hsieh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Changhua 500, Taiwan
| | - Ming-Feng Hou
- Cancer Center, Kaohsiung Medical University Hospital, Kaohsiung City 807, Taiwan
| | - Deng-Chyang Wu
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung City 807, Taiwan
- Department of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City 807, Taiwan
- Cancer Center, Kaohsiung Medical University Hospital, Kaohsiung City 807, Taiwan
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Chang WL, Kao CY, Wu CT, Huang AH, Wu JJ, Yang HB, Cheng HC, Sheu BS. Gemifloxacin can partially overcome quinolone resistance of H. pylori with gyrA mutation in Taiwan. Helicobacter 2012; 17:210-5. [PMID: 22515359 DOI: 10.1111/j.1523-5378.2012.00935.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUNDS The levofloxacin resistance caused by gyrA gene mutation is rising rapidly to limit wide application for Helicobacter pylori eradication. We investigated whether gemifloxacin has a superior antimicrobial activity to levofloxacin against H. pylori. MATERIALS AND METHODS Forty-four consecutive clinical H. pylori isolates with levofloxacin resistance and 80 randomly selected levofloxacin-sensitive controls were tested for gemifloxacin sensitivity by E-test. The resistance to levofloxacin or gemifloxacin was defined as minimal inhibitory concentration (MIC) > 1 mg/L. The clinical features and GyrA mutation patterns checked by direct sequencing were also analyzed to assess its association with the H. pylori gemifloxacin resistance. RESULTS All levofloxacin-sensitive H. pylori isolates were sensitive to gemifloxacin. Eight strains (18.2%) resistant to levofloxacin could be still sensitive to gemifloxacin. Gemifloxacin achieved a 5-time lower in MIC levels against levofloxacin-resistant isolates. Nearly all levofloxacin-resistant isolates (97.7%, 43/44) had GyrA mutation at amino acid position 87 or 91. Double mutation sites may play dual roles in quinolone resistance, as N87K plus H57Y or D91N plus V77A mutations showed high-level resistance to both quinolones; whereas D91Y plus A97V or D91N plus A97V mutations showed low level levofloxacin resistance to become sensitive to gemifloxacin. In H. pylori isolates with single N87K, D91Y or D91N mutation, near 20% was gemifloxacin-sensitive and levofloxacin-resistant. The gemifloxacin-resistant rate of H. pylori was higher in patients with gastric ulcer than in those without (p <.05). CONCLUSION Gemifloxacin is superior to levofloxacin in antimicrobial activity against clinical H. pylori isolates, and even overcome some levofloxacin resistance.
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Affiliation(s)
- Wei-Lun Chang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Silva O, Viegas S, de Mello-Sampayo C, Costa MJP, Serrano R, Cabrita J, Gomes ET. Anti-Helicobacter pylori activity of Terminalia macroptera root. Fitoterapia 2012; 83:872-6. [PMID: 22465506 DOI: 10.1016/j.fitote.2012.03.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 03/09/2012] [Accepted: 03/12/2012] [Indexed: 12/17/2022]
Abstract
The root of Terminalia macroptera Guill. & Perr. (Combretaceae) is widely used in African traditional medicine to treat various infectious diseases, including stomach-associated diseases. This study investigates the in vitro activity of T. macroptera root extract against reference strains and clinical isolates of H. pylori and attempts to localize the extract bioactivity. T. macroptera hydroethanol (80% V/V) root extract (Tmr) activity was tested against three standard strains and sixty two clinical strains of H. pylori. Tmr liquid-liquid partition fractions were screened against twenty H. pylori strains. Qualitative analysis of Tmr and its fractions was performed by HPLC-UV/DAD. The antibiotic characterization of the H. pylori strains revealed that 20% of the tested clinical isolates were resistant to at least two of the three antibiotics belonging to the main groups of antibiotics used in multi-therapy to eradicate H. pylori infections. In contrast, Tmr showed anti-H. pylori activity against the majority (92%) of the tested strains (MIC(50) and MIC(90)=200 μg/ml). The Tmr water liquid-liquid fraction (Tmr-3) and the precipitate obtained from this fraction (Tmr-5) were the most active tested samples, showing a MIC(50) of 100 μg/ml. The present work proves the in vitro activity of T. macroptera against H. pylori, thus confirming the utility of this traditional medicinal plant to treat stomach complaints due to H. pylori infection. The main compounds of Tmr and of Tmr-3 were the ellagitannins terchebulin and punicalagin. These compounds can be considered as markers of T. macroptera root active extracts against H. pylori.
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Affiliation(s)
- Olga Silva
- iMed.UL, Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal.
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Helicobacter pylori eradication therapy in obese patients undergoing gastric bypass surgery--fourteen days superior to seven days? Obes Surg 2012; 21:1377-81. [PMID: 20838918 DOI: 10.1007/s11695-010-0254-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The high prevalence of Helicobacter pylori (HP) in our obese population undergoing Roux-en-Y bypass gastric surgery (69.4%) and the concern that it may exacerbate postoperative foregut symptoms and increase gastric cancer risk led us to adopt a policy of HP systematic eradication in this group of patients. Our aim, in obese patients undergoing bypass gastric surgery, was to compare effectivity of 7- and 14-days clarithromycin-based triple therapy as the first-line treatment for HP eradication. METHODS Three hundred seventy-three patients [mean age 41.2 ± 10.3 years; 313 women (83.9%)] were HP positive determined by histology or urea breath test. In 2005, 94 patients (Group A) were treated with a 7-days triple therapy-proton pump inhibitor (PPI) b.i.d., clarithromycin (CL) 500 mg b.i.d., and amoxicillin (AMX) 1,000 mg b.i.d. Since 2006, 279 patients (Group B) were treated with a similar 14-days drug regimen-PPI b.i.d., CL 500 mg b.i.d., and AMX 1,000 mg b.i.d. Posttreatment HP status was assessed by C13 urea breath test 4-6 weeks after the end of therapy. RESULTS The eradication rates were 67.0% (Group A) and 79.9% (Group B). The eradication rate achieved with 14-days triple therapy was significantly higher than with 7-days triple therapy (OR = 1.96; 95% CI: 1.16-3.30; p = 0.016). CONCLUSIONS A 14-days triple therapy is more effective than 7-days triple therapy suggesting this regimen should be the first-line therapy for HP eradication in Portuguese obese patients undergoing bypass gastric surgery.
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Gisbert JP. Rescue Therapy for Helicobacter pylori Infection 2012. Gastroenterol Res Pract 2012; 2012:974594. [PMID: 22536225 PMCID: PMC3299261 DOI: 10.1155/2012/974594] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 12/10/2011] [Indexed: 12/18/2022] Open
Abstract
Helicobacter pylori infection is the main cause of gastritis, gastroduodenal ulcer disease, and gastric cancer. After 30 years of experience in H. pylori treatment, however, the ideal regimen to treat this infection has still to be found. Nowadays, apart from having to know well first-line eradication regimens, we must also be prepared to face treatment failures. In designing a treatment strategy, we should not only focus on the results of primary therapy alone but also on the final-overall-eradication rate. The choice of a "rescue" treatment depends on which treatment is used initially. If a first-line clarithromycin-based regimen was used, a second-line metronidazole-based treatment (quadruple therapy) may be used afterwards, and then a levofloxacin-based combination would be a third-line "rescue" option. Alternatively, it has recently been suggested that levofloxacin-based "rescue" therapy constitutes an encouraging 2nd-line strategy, representing an alternative to quadruple therapy in patients with previous PPI-clarithromycin-amoxicillin failure, with the advantage of efficacy, simplicity and safety. In this case, quadruple regimen may be reserved as a 3rd-line "rescue" option. Even after two consecutive failures, several studies have demonstrated that H. pylori eradication can finally be achieved in almost all patients if several "rescue" therapies are consecutively given.
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Affiliation(s)
- Javier P. Gisbert
- Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IP), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), 28006 Madrid, Spain
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Variability in Prevalence ofHelicobacter pyloriStrains Resistant to Clarithromycin and Levofloxacin in Southern Poland. Gastroenterol Res Pract 2012; 2012:418010. [PMID: 22693490 PMCID: PMC3368181 DOI: 10.1155/2012/418010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 03/15/2012] [Accepted: 03/29/2012] [Indexed: 02/07/2023] Open
Abstract
Background. An increasing resistance ofHelicobacter pyloristrains to antimicrobial agents is the serious therapeutic problem. The aim of this study was to compare the primary and secondary resistance ofH. pyloristrains isolated between 2006–2008 (data published) and 2009–2011 to clarithromycin and levofloxacin.Material and Methods. 220 dyspeptic patients (153 before treatment, 67 after), were enrolled in the study. 51H. pyloristrains were isolated. MIC values of clarithromycin and levofloxacin were determined by theE-test method. The statistical analysis was conducted with theχ2test with Yates correction at the 0.05 significance level (P≤0.05).Results. Between 2006 and 2008, 34% (39/115) ofH. pyloristrains were resistant to clarithromycin (primary 21% (19/90), secondary 80% (20/25)). 5% (6/115) of strains were resistant to levofloxacin (primary 2% (2/90), secondary 16% ((4/25); data published) Between 2009–2011, 22% (11/51) ofH. pyloristrains were resistant to clarithromycin (primary 19% (8/43), secondary 38% (3/8)). 16% (8/51) of strains were resistant to levofloxacin (primary 12% (5/43), secondary 38% (3/8)).Conclusion. The present study has shown the increasing amount of resistantH. pyloristrains isolated from patients in Southern Poland to levofloxacin and decreasing number of resistant strains to clarithromycin.
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Alaska sentinel surveillance study of Helicobacter pylori isolates from Alaska Native persons from 2000 to 2008. J Clin Microbiol 2011; 49:3638-43. [PMID: 21813726 DOI: 10.1128/jcm.01067-11] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Helicobacter pylori infection is more common in Alaska Native persons than in the general U.S. population, with seroprevalence to H. pylori approaching 75%. Previous studies in Alaska have demonstrated elevated proportions of antimicrobial resistance among H. pylori isolates. We analyzed H. pylori data from the Centers for Disease Control and Prevention's sentinel surveillance in Alaska from January 2000 to December 2008 to determine the proportion of culture-positive biopsy specimens with antimicrobial resistance from Alaska Native persons undergoing endoscopy. The aim of the present study was to monitor antimicrobial resistance of H. pylori isolates over time and by region in Alaska Native persons. Susceptibility testing of H. pylori isolates to metronidazole, clarithromycin, amoxicillin, and tetracycline was performed using agar dilution. Susceptibility testing for levofloxacin was performed by Etest. Overall, 45% (532/1,181) of persons undergoing upper endoscopy were culture positive for H. pylori. Metronidazole resistance was demonstrated in isolates from 222/531 (42%) persons, clarithromycin resistance in 159/531 (30%) persons, amoxicillin resistance in 10/531 (2%) persons, and levofloxacin resistance in 30/155 (19%) persons; no tetracycline resistance was documented. The prevalence of metronidazole, clarithromycin, and levofloxacin resistance varied by region. Female patients were more likely than male patients to demonstrate metronidazole (P < 0.05) and clarithromycin (P < 0.05) resistance. No substantial change in the proportion of persons with resistant isolates was observed over time. Resistance to metronidazole, clarithromycin, and levofloxacin is more common among H. pylori isolates from Alaska Native persons than those from elsewhere in the United States.
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Oleastro M, Cabral J, Ramalho PM, Lemos PS, Paixao E, Benoliel J, Santos A, Lopes AI. Primary antibiotic resistance of Helicobacter pylori strains isolated from Portuguese children: a prospective multicentre study over a 10 year period. J Antimicrob Chemother 2011; 66:2308-11. [DOI: 10.1093/jac/dkr293] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Multicenter survey of routine determinations of resistance of Helicobacter pylori to antimicrobials over the last 20 years (1990 to 2009) in Belgium. J Clin Microbiol 2011; 49:2200-9. [PMID: 21450969 DOI: 10.1128/jcm.02642-10] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
We analyzed the rates of antimicrobial resistance of Helicobacter pylori strains isolated from patients from 1990 to 2009 and identified risk factors associated with resistance. Gastric biopsy specimens were collected from several digestive disease centers in Brussels, Belgium. We routinely performed antimicrobial susceptibility testing for clarithromycin (CLR), metronidazole, amoxicillin, tetracycline, and ciprofloxacin. Evaluable susceptibility testing was obtained for 9,430 strains isolated from patients who were not previously treated for Helicobacter pylori infection (1,527 isolates from children and 7,903 from adults) and 1,371 strains from patients who were previously treated (162 isolates from children and 1,209 from adults). No resistance to amoxicillin was observed, and tetracycline resistance was very rare (<0.01%). Primary metronidazole resistance remained stable over the years, with significantly lower rates for isolates from children (23.4%) than for isolates from adults (30.6%). Ciprofloxacin resistance remained rare in children, while it increased significantly over the last years in adults. Primary clarithromycin resistance increased significantly, reaching peaks in 2000 for children (16.9%) and in 2003 for adults (23.7%). A subsequent decrease of resistance rates down to 10% in both groups corresponded to a parallel decrease in macrolide consumption during the same period. Multivariate logistic regression revealed that female gender, age of the patient of 40 to 64 years, ethnic background, the number of previously unsuccessful eradication attempts, and the different time periods studied were independent risk factors of resistance to clarithromycin, metronidazole, and ciprofloxacin. Our study highlights the need to update local epidemiological data. Thus, the empirical CLR-based triple therapy proposed by the Maastricht III consensus report remains currently applicable to our population.
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Abstract
INTRODUCTION Helicobacter pylori eradication rates have fallen considerably in recent years. Antibiotic resistance is thought to be rising. OBJECTIVES To examine the levels of resistance to metronidazole (MTZ) and clarithromycin (CLA) in H. pylori, isolates were taken in a reference centre in Ireland from 2007 to 2008 and were compared to a similar cohort from a study in 1997. METHOD Antimicrobial susceptibilities were tested by E-test. Frequencies of spontaneous metronidazole and clarithromycin resistance were measured on an agar plate containing the antibiotics at concentrations of 2x and 4x minimum inhibition concentration values. Clinical data were obtained from charts, laboratory and endoscopy reports. RESULTS Two hundred and twenty-two patients were analyzed, 98 were females. Colonies amenable to culture were grown in 219 patients. Thirty-seven had prior attempts at eradication therapy (all with amoxicillin-CLA-proton pump inhibitor. A total of 31.5% of the patients had strains resistant to MTZ and 13.2% of the patients were noted to have strains resistant to CLA. About 8.6% of the patients had strains resistant to both the agents. CLA resistance was 9.3% in those who had no prior eradication therapy compared with 32.4% of those who had. CLA resistance increased from 3.9%, among treatment-naive patients in 1997, to 9.3% in our study. MTZ resistance was 29.1% in the treatment-naive population. In 1997, MTZ resistance in the treatment-naive cohort was 27.1%. MTZ resistance was more likely to occur in females (35.4 vs. 28.5%) than in males. CONCLUSION This study shows that resistance to CLA among Irish patients infected with H. pylori has increased since 1997. The future of treatment may well lie in the widespread use of sensitivity testing before the treatment. This would promote an accurate treatment.
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Abstract
It is accepted that the success of Helicobacter pylori eradication treatment using standard triple therapy is declining. Resistance, particularly to clarithromycin, has been shown in numerous countries to be rising to a level where the use of standard triple therapy in its current form may no longer be justified. The two major factors influencing resistance are prior exposure to the antibiotic and compliance with therapy. Regimes based on bismuth and levofloxacin, which had previously been mainly second-line options, are now emerging as superior first-line options. Trials of sequential and concomitant therapies are also showing the usefulness of these treatments in different populations. Options for third and subsequent line therapies include furazolidone and rifabutin-based regimes. Susceptibility testing should be performed to maintain accurate data on resistance levels, and has also clinical utility in difficult to eradicate cases. None of these, however, will be successful unless compliance is improved upon. If compliance is assured and eradication confirmation pursued, it has been repeatedly illustrated that near full eradication is achievable.
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Affiliation(s)
- Anthony O'Connor
- Department of Gastroenterology, Adelaide and Meath Hospital incorporating the National Children's Hospital/Trinity College Dublin, Tallaght, Dublin 24, Ireland.
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Abstract
Helicobacter pylori infection is the main known cause of gastritis, gastroduodenal ulcer disease and gastric cancer. After more than 20 years of experience in H. pylori treatment, however, the ideal regimen to treat this infection has still to be found. Nowadays, apart from having to know well first-line eradication regimens, we must also be prepared to face treatment failures. Therefore, in designing a treatment strategy we should not focus on the results of primary therapy alone, but also on the final (overall) eradication rate. The choice of a 'rescue' treatment depends on which treatment is used initially. If a first-line clarithromycin-based regimen was used, a second-line metronidazole-based treatment (quadruple therapy) may be used afterwards, and then a levofloxacin-based combination would be a third-line 'rescue' option. Alternatively, it has recently been suggested that levofloxacin-based 'rescue' therapy constitutes an encouraging second-line strategy, representing an alternative to quadruple therapy in patients with previous PPI-clarithromycin-amoxicillin failure, with the advantage of efficacy, simplicity and safety. In this case, quadruple regimen may be reserved as a third-line 'rescue' option. Finally, rifabutin-based 'rescue' therapy constitutes an encouraging empirical fourth-line strategy after multiple previous eradication failures with key antibiotics such as amoxicillin, clarithromycin, metronidazole, tetracycline, and levofloxacin. Even after two consecutive failures, several studies have demonstrated that H. pylori eradication can finally be achieved in almost all patients if several 'rescue' therapies are consecutively given. Therefore, the attitude in H. pylori eradication therapy failure, even after two or more unsuccessful attempts, should be to fight and not to surrender.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de la Princesa and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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Chisholm SA, Owen RJ. Frequency and molecular characteristics of ciprofloxacin- and rifampicin-resistant Helicobacter pylori from gastric infections in the UK. J Med Microbiol 2009; 58:1322-1328. [PMID: 19589906 DOI: 10.1099/jmm.0.011270-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Treatment failure with standard Helicobacter pylori eradication regimes may require the use of 'rescue' therapies containing fluoroquinolones or rifamycins. The susceptibilities of H. pylori in the UK to such antimicrobials are unknown; therefore, this study aimed to determine the frequencies and molecular markers of resistance. Ciprofloxacin and rifampicin susceptibilities were determined by Etest and/or disc diffusion for 255 isolates of H. pylori, including 171 isolates from adult dyspeptic patients with refractive infections. Mutations in known resistance-determining regions of gyrA and rpoB were determined. The ciprofloxacin resistance rate was 7.5 %, and gyrA mutations, predominantly at codon position 91, were identified in most resistant isolates. One isolate (<1 %) had an unequivocal rifampicin-resistant phenotype by Etest yet had no associated mutations in the rpoB gene. As resistance rates were low in H. pylori isolates, including those from patients with refractive infections, it was concluded that fluoroquinolones or rifamycins might be considered in the UK for inclusion in 'rescue' therapies.
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Affiliation(s)
- Stephanie A Chisholm
- Gastrointestinal, Emerging and Zoonotic Infections Department, Centre for Infections, Health Protection Agency, 61 Colindale Avenue, London NW9 5HT, UK
| | - Robert J Owen
- Gastrointestinal, Emerging and Zoonotic Infections Department, Centre for Infections, Health Protection Agency, 61 Colindale Avenue, London NW9 5HT, UK
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Chang WL, Sheu BS, Cheng HC, Yang YJ, Yang HB, Wu JJ. Resistance to metronidazole, clarithromycin and levofloxacin of Helicobacter pylori before and after clarithromycin-based therapy in Taiwan. J Gastroenterol Hepatol 2009; 24:1230-5. [PMID: 19476562 DOI: 10.1111/j.1440-1746.2009.05829.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Clarithromycin-based triple therapy has been commonly applied as the first-line therapy for Helicobacter pylori eradication. Levofloxacin could serve as an alternative in either first-line or second-line regimens. This study surveyed the prevalence of levofloxacin resistance of H. pylori isolates in naive patients and in patients with a failed clarithromycin-based triple therapy. METHODS The study collected the H. pylori isolates from 180 naive patients and 47 patients with a failed clarithromycin-based triple therapy. Their in vitro antimicrobial resistance was determined by E-test. RESULTS The naive H. pylori isolates had resistance rates for amoxicillin, levofloxacin, clarithromycin and metronidazole of 0%, 9.4%, 10.6% and 26.7%, respectively. An evolutional increase of the primary levofloxacin resistance was observed in isolates collected after 2004, as compared to isolates collected before 2004 (16.3% vs 3.2%, P = 0.003). There was no evolutional increment of the primary clarithromycin resistance. The clarithromycin resistance elevated significantly after a failed clarithromycin-based triple therapy (78.7% vs 10.6%, P < 0.001). The post-treatment isolates remained to have a levofloxacin resistance rate of near 17%, but the levofloxacin-resistant isolates were correlated with a higher incidence of metronidazole resistance (P = 0.023). No strain was found to be resistant to amoxicillin even after eradication failure. CONCLUSION The levofloxacin resistance of naive H. pylori remains less than 10% in Taiwan. With relatively lower resistance to levofloxacin than to metronidazole of the H. pylori isolates collected after a failed clarithromycin-based therapy, proton pump inhibitor-levofloxacin-amoxicillin may be an alternative choice to serve as the second-line therapy.
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Affiliation(s)
- Wei-Lun Chang
- Department of Internal Medicine, Medical College, National Cheng Kung University, Tainan, Taiwan
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Nishizawa T, Suzuki H, Hibi T. Quinolone-Based Third-Line Therapy for Helicobacter pylori Eradication. J Clin Biochem Nutr 2009; 44:119-24. [PMID: 19308265 PMCID: PMC2654467 DOI: 10.3164/jcbn.08-220r] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Accepted: 09/11/2008] [Indexed: 12/21/2022] Open
Abstract
Currently, a standard third-line therapy for Helicobacter pylori (H. pylori) eradication remains to be established. Quinolones show good oral absorption, no major side effects, and marked activity against H. pylori. Several authors have studied quinolone-based third-line therapy and reported encouraging results, with the reported H. pylori cure rates ranging from 60% to 84%. Resistance to quinolones is easily acquired, and the resistance rate is relatively high in countries with a high consumption rate of these drugs. We recently reported a significant difference in the eradication rate obtained between patients infected with gatifloxacin-susceptible and gatifloxacin-resistant H. pylori, suggesting that the selection of quinolones for third-line therapy should be based on the results of drug susceptibility testing. As other alternatives of third-line rescue therapies, rifabutin-based triple therapy, high-dose proton pump inhibitor/amoxicillin therapy and furazolidone-based therapy have been suggested.
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Affiliation(s)
- Toshihiro Nishizawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo 160-8582, Japan
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Kuo CH, Hu HM, Kuo FC, Hsu PI, Chen A, Yu FJ, Tsai PY, Wu IC, Wang SW, Li CJ, Weng BC, Chang LL, Jan CM, Wang WM, Wu DC. Efficacy of levofloxacin-based rescue therapy for Helicobacter pylori infection after standard triple therapy: a randomized controlled trial. J Antimicrob Chemother 2009; 63:1017-24. [PMID: 19246508 DOI: 10.1093/jac/dkp034] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES This prospective study was designed to determine the efficacy of a levofloxacin-based rescue therapy for Helicobacter pylori infection after failure of standard triple therapies. We also surveyed the predictors of this rescue therapy. PATIENTS AND METHODS From June 2005 to March 2007, 1036 patients infected with H. pylori received standard triple regimens (proton pump inhibitor, clarithromycin and amoxicillin). H. pylori eradication was achieved in 855 (82.5%) subjects. One hundred and sixty-six eradication-failure patients were enrolled and randomly assigned to receive a 7 day eradication therapy with esomeprazole, bismuth subcitrate, tetracycline and metronidazole (EBTM) or esomeprazole, amoxicillin and levofloxacin (EAL). Follow-up endoscopy was done 16 weeks later to assess the treatment response. Patients' response, CYP2C19 genotypes and antibiotic resistances were also examined. RESULTS Intention-to-treat analysis revealed that both groups showed similar eradication rates [EBTM 63.9%; 95% confidence interval (CI): 53.6-74.2 and EAL 69.9%; 95% CI: 60.1-79.7] (P = 0.89). Per-protocol results were EBTM = 84.1% (95% CI: 75.1-93.1) and EAL = 75.3% (95% CI: 65.8-84.8) (P = 0.82). Both regimens had similar compliance (P = 0.32), but the EBTM group had more adverse events (P = 0.27). Logistic regression analysis showed that poor compliance, CYP2C19 homozygous extensive metabolizer genotype and levofloxacin resistance were important predictors for eradication failure. CONCLUSIONS The EAL regimen can achieve an efficacy similar to that of the standard EBTM therapy. It may be very useful in countries where bismuth salts are not available. Compliance, CYP2C19 genotype and resistances to antibiotics may influence the outcome of levofloxacin-based rescue therapy. It seems advisable to reserve levofloxacin for rescue treatment to avoid an increase in the resistance phenomenon.
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Wenzhen Y, Kehu Y, Bin M, Yumin L, Quanlin G, Donghai W, Lijuan Y. Moxifloxacin-based triple therapy versus clarithromycin-based triple therapy for first-line treatment of Helicobacter pylori infection: a meta-analysis of randomized controlled trials. Intern Med 2009; 48:2069-76. [PMID: 20009394 DOI: 10.2169/internalmedicine.48.2344] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Moxifloxacin-based triple therapy has been suggested as an alternative first line therapy to clarithromycin-based triple therapy for Helicobacter pylori infection. AIMS To systematically review the efficacy and tolerance of moxifloxacin-based triple therapy, and to conduct a meta-analysis of studies comparing this regimen with clarithromycin-based triple therapy. METHODS A search of The Cochrane Library, PUBMED, EMBASE, EBM Review databases, Science Citation Index Expanded, and CMB (Chinese Biomedical Literature Database) was performed. Randomized controlled trials comparing moxifloxacin-based triple therapy to gold standard triple therapy in the first-line treatment of Helicobacter pylori infection were selected for meta-analysis. Relative risk was used as a measure of the effect of the two above-mentioned regimens with a fixed-effects model using the methods of DerSimonian and Laird. RESULTS Four randomized controlled trials totaling 772 patients were included. The meta-analysis showed that the mean eradication rate was 84.1 (318/378) in the moxifloxacin-based triple therapy group and 73.6 (290/394) in the clarithromycin-based triple therapy group; there was statistical significance between the two groups (RR, 1.13; 95% CI, 1.01, 1.27; P=0.04). There were no statistically significant difference in the overall side effects (RR, 0.61; 95% CI, 0.25, 1.48; P<0.28). CONCLUSIONS Moxifloxacin-based triple therapy is more effective and does not increase the incidence of overall side effects compared to clarithromycin-based triple therapy in the treatment of H. pylori infection.
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Affiliation(s)
- Yuan Wenzhen
- Evidence-Based Medicine Center of Lanzhou University, Lanzhou, China
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Kiliç ZMY, Köksal AS, Cakal B, Nadir I, Ozin YO, Kuran S, Sahin B. Moxifloxacine plus amoxicillin and ranitidine bismuth citrate or esomeprazole triple therapies for Helicobacter pylori infection. Dig Dis Sci 2008; 53:3133-7. [PMID: 18465244 DOI: 10.1007/s10620-008-0285-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2007] [Accepted: 04/09/2008] [Indexed: 12/23/2022]
Abstract
Up to 20% of patients, or even more, will fail to obtain eradication after a standard triple therapy. The aim of this study is to evaluate the efficacy of moxifloxacine-containing regimens in the first-line treatment of Helicobacter pylori. One hundred and twenty H. pylori-positive patients were randomized into four groups to receive one of the following 14-day treatments: ranitidine bismuth citrate (RBC) 400 mg b.d. plus amoxicillin 1 g b.d. and clarithromycin 500 mg b.d. (RAC group, n = 30); RBC 400 mg b.d. plus moxifloxacine 400 mg o.d. and amoxicillin 1,000 mg b.d. (RAM group, n = 30); esomeprazole 40 mg b.d. plus amoxicillin 1,000 mg b.d. plus clarithromycin 500 mg b.d. (EAC group, n = 30); and esomeprazole 40 mg b.d. plus amoxicillin 1,000 mg b.d. plus moxifloxacine 400 mg o.d. (EAM group, n = 30). Eradication was assessed by (13)C urea breath test 8 weeks after therapy. Per-protocol and intention-to-treat eradication was achieved in 23 out of 30 patients (76.7%, 95% confidence interval [CI]: 61-92) in the RAC group, in 20 patients (66.7%, 95% CI: 49-84) in the RAM group, in 16 patients in the EAM group (53.3%, 95% CI: 34-71), and in 19 patients in the EAC group (63.3%, 95% CI: 54-72). Mild or moderate side-effects were significantly more common in the EAM group (70%) compared to the RAC (36.6%), RAM (43.3%), and EAC (56.6%) groups (P = 0.03). From our results, we conclude that moxifloxacine-containing triple therapies have neither eradication nor compliance advantages over standard triple therapies. Further studies with new antibiotic associations are needed for the better eradication of H. pylori in developing regions of the world.
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Affiliation(s)
- Zeki Mesut Yalin Kiliç
- Department of Gastroenterology, Türkiye Yüksek Ihtisas Hospital, Sihhiye, Ankara, Turkey.
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Antibiotic resistance of Helicobacter pylori from patients in Ile-Ife, South-west, Nigeria. Afr Health Sci 2008; 7:143-7. [PMID: 18052867 DOI: 10.5555/afhs.2007.7.3.143] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Helicobacter pylori has become recognized as a major cause of gastroduodenal diseases in man. Evidence indicates that once acquired, H. pylori persists, usually for life unless eradicated by antimicrobial therapy. Over the past few years, we have accumulated some knowledge of the epidemiology of H. pylori in Ile-Ife, South-West Nigeria. In one collaborative study, we detected H. pylori in 195 (73%) patients referred for endoscopy at Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC). Furthermore we have observed a variegated gastric inflammatory response and atrophy including atrophic pangastritis but are yet to demonstrate MALToma in any of our patients. In addition we have demonstrated that dental plaque is a possible source of gastric H. pylori infection and such an endogenous source could account for difficulty in eradication leading to re-infection. Presently, infected patients are treated with standard combination therapy made up of amoxycilin and ciprofloxacin with a proton pump inhibitor/bismuth. Reports however have shown that the incidence of antimicrobial resistance in Helicobacter pylori is a growing problem and which has been linked with failures in treatment and eradication. Given this situation it has become necessary to have information about the susceptibility of isolates to particular antimicrobial agents before the selection of an appropriate treatment regimen. OBJECTIVES More recently, we sought to study antimicrobial susceptibility of locally isolated H. pylori strains. METHODS We subjected 32 isolates to antimicrobial susceptibility testing against seven agents. RESULTS All the isolates showed multiple acquired antimicrobial resistance as they were all resistant to amoxicillin, clarithromycin, metronidazole, while 29/31, 27/31 showed resistance to rifampicin and tetracycline respectively. Five (15.6%) of these isolates showed resistance to ciprofloxacin. CONCLUSIONS Our findings suggest that H. pylori strains isolated within our study environment have acquired resistance to all the commonly prescribed antibiotics. On the basis of the findings it would be necessary to re-evaluate the eradication treatment regime in our setting.
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Abstract
Helicobacter pylori (H pylori) infection is the main cause of gastritis, gastroduodenal ulcer disease, and gastric cancer. After more than 20 years of experience in H pylori treatment, in my opinion, the ideal regimen to treat this infection is still to be found. Currently, apart from having to know first-line eradication regimens well, we must also be prepared to face treatment failures. Therefore, in designing a treatment strategy we should not focus on the results of primary therapy alone, but also on the final (overall) eradication rate. The choice of a “rescue” treatment depends on which treatment is used initially. If a clarithromycin-based regimen was used initially, a subsequent metronidazole-based treatment (quadruple therapy) may be used afterwards, and then a levofloxacin-based combination would be a third “rescue” option. Alternatively, it has recently been suggested that levofloxacin-based rescue therapy constitutes an encouraging second-line strategy, representing an alternative to quadruple therapy in patients with previous PPI-clarithromycin-amoxicillin failure, with the advantage of efficacy, simplicity and safety. In this case, a quadruple regimen may be reserved as a third-line rescue option. Finally, rifabutin-based rescue therapy constitutes an encouraging empirical fourth-line strategy after multiple previous eradication failures with key antibiotics such as amoxicillin, clarithromycin, metronidazole, tetracycline, and levofloxacin. Even after two consecutive failures, several studies have demonstrated that H pylori eradication can finally be achieved in almost all patients if several rescue therapies are consecutively given. Therefore, the attitude in H pylori eradication therapy failure, even after two or more unsuccessful attempts, should be to fight and not to surrender.
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Jones KR, Cha JH, Merrell DS. Who's Winning the War? Molecular Mechanisms of Antibiotic Resistance in Helicobacter pylori. CURRENT DRUG THERAPY 2008; 3:190-203. [PMID: 21765819 DOI: 10.2174/157488508785747899] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The ability of clinicians to wage an effective war against many bacterial infections is increasingly being hampered by skyrocketing rates of antibiotic resistance. Indeed, antibiotic resistance is a significant problem for treatment of diseases caused by virtually all known infectious bacteria. The gastric pathogen Helicobacter pylori is no exception to this rule. With more than 50% of the world's population infected, H. pylori exacts a tremendous medical burden and represents an interesting paradigm for cancer development; it is the only bacterium that is currently recognized as a carcinogen. It is now firmly established that H. pylori infection is associated with diseases such as gastritis, peptic and duodenal ulceration and two forms of gastric cancer, gastric adenocarcinoma and mucosa-associated lymphoid tissue (MALT) lymphoma. With such a large percentage of the population infected, increasing rates of antibiotic resistance are particularly vexing for a treatment regime that is already fairly complicated; treatment consists of two antibiotics and a proton pump inhibitor. To date, resistance has been found to all primary and secondary lines of antibiotic treatment as well as to drugs used for rescue therapy.
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Affiliation(s)
- Kathleen R Jones
- Department of Microbiology and Immunology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814, USA
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41
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Ndip RN, Malange Takang AE, Ojongokpoko JEA, Luma HN, Malongue A, Akoachere JFTK, Ndip LM, MacMillan M, Weaver LT. Helicobacter pylori isolates recovered from gastric biopsies of patients with gastro-duodenal pathologies in Cameroon: current status of antibiogram. Trop Med Int Health 2008; 13:848-54. [PMID: 18384477 DOI: 10.1111/j.1365-3156.2008.02062.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the prevalence of Helicobacter pylori in patients with gastro-duodenal pathologies and the susceptibility patterns of isolates to the currently recommended antibiotic treatment regimen used in Cameroon. METHODS Consecutive dyspeptic patients referred to Douala General Hospital, Cameroon for endoscopy were recruited in the study. Gastric biopsies were collected from the patients and H. pylori isolated and identified following standard microbiology and biochemical techniques. Antibiotic susceptibility was determined by disk diffusion and agar dilution methods against clarithromycin, tetracycline, amoxicillin and metronidazole. Data were analysed using chi-square test and significance considered at P < 0.05. RESULTS Seventy-one (92.2%) of the 77 patients (mean age 44.5 +/- 15.7, range 15-77 years) were positive for H. pylori. The antibiotic susceptibility rates were 56% for tetracycline, 55.3% for clarithromycin, 14.4% for amoxicillin and 6.8% for metronidazole. The prevalence of clarithromycin resistance in males vs. females was 42.1%vs. 46.7%, while for metronidazole it was 89.5%vs. 94.7% (P > 0.05). Antimicrobial susceptibility results also revealed 12 antibiotypes based on resistance to the antimicrobial agents investigated. The resistance pattern, amoxicillin and metronidazole (AMR(R) MET(R)) was the most common (23.7%) amongst the isolates. More than 60% of the isolates exhibited multi-drug resistance to three or four antibiotics. CONCLUSION Multi-drug resistance is common against the current treatment regimen in Cameroon and, therefore, calls for urgent studies involving newer and broad spectrum antibiotics to address the problem.
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Affiliation(s)
- Roland N Ndip
- Department of Biochemistry and Microbiology, Faculty of Science, University of Buea, Buea, Cameroon.
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Gisbert JP, Bermejo F, Castro-Fernández M, Pérez-Aisa A, Fernández-Bermejo M, Tomas A, Barrio J, Bory F, Almela P, Sánchez-Pobre P, Cosme A, Ortiz V, Niño P, Khorrami S, Benito LM, Carneros JA, Lamas E, Modolell I, Franco A, Ortuño J, Rodrigo L, García-Durán F, O'Callaghan E, Ponce J, Valer MP, Calvet X. Second-line rescue therapy with levofloxacin after H. pylori treatment failure: a Spanish multicenter study of 300 patients. Am J Gastroenterol 2008; 103:71-6. [PMID: 17764498 DOI: 10.1111/j.1572-0241.2007.01500.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM Quadruple therapy is generally recommended as second-line therapy after Helicobacter pylori (H. pylori) eradication failure. However, this regimen requires the administration of four drugs with a complex scheme, is associated with a relatively high incidence of adverse effects, and bismuth salts are not available worldwide anymore. Our aim was to evaluate the efficacy and tolerability of a triple second-line levofloxacin-based regimen in patients with H. pylori eradication failure. DESIGN Prospective multicenter study. PATIENTS in whom a first treatment with proton pump inhibitor-clarithromycin-amoxicillin had failed. INTERVENTION A second eradication regimen with levofloxacin (500 mg b.i.d.), amoxicillin (1 g b.i.d.), and omeprazole (20 mg b.i.d.) was prescribed for 10 days. OUTCOME Eradication was confirmed with (13)C-urea breath test 4-8 wk after therapy. Compliance with therapy was determined from the interview and the recovery of empty envelopes of medications. Incidence of adverse effects was evaluated by means of a specific questionnaire. RESULTS Three hundred consecutive patients were included. Mean age was 48 yr, 47% were male, 38% had peptic ulcer, and 62% functional dyspepsia. Almost all (97%) patients took all the medications correctly. Per-protocol and intention-to-treat eradication rates were 81% (95% CI 77-86%) and 77% (73-82%). Adverse effects were reported in 22% of the patients, mainly including nausea (8%), metallic taste (5%), abdominal pain (3%), and myalgias (3%); none of them were severe. CONCLUSION Ten-day levofloxacin-based rescue therapy constitutes an encouraging second-line strategy, representing an alternative to quadruple therapy in patients with previous proton pump inhibitor-clarithromycin-amoxicillin failure, being simple and safe.
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Lee CC, Lee VWY, Chan FKL, Ling TKW. Levofloxacin-resistant Helicobacter pylori in Hong Kong. Chemotherapy 2007; 54:50-3. [PMID: 18073471 DOI: 10.1159/000112416] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2006] [Accepted: 06/03/2007] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fluoroquinolone-resistant Helicobacter pylori emerged in 1995 and the resistance was due to point mutation in the gyrA gene. In this study we investigate the resistance mechanism and the antimicrobial susceptibilities of clarithromycin, metronidazole, amoxicillin, tetracycline and telithromycin against levofloxacin-resistant H. pylori in Hong Kong. METHODS One hundred and ninety-one nonduplicate H. pylori isolates were collected during 2004 and 2005, and 25 isolates with levofloxacin zone sizes less than 30 mm were selected for minimal inhibitory concentration determination by agar dilution, gyrA gene amplication and sequencing the amplified gyrA gene. RESULTS The prevalence of levofloxacin-resistant H. pylori was 11.5% (22/191). Among these levofloxacin-resistant strains, 7 (31.8%) and 10 (45.5%) were resistant to clarithromycin and metronidazole, respectively, 17 (77.3%) had point mutations in gyrA gene at amino acids 87, 91 and 130 and the most frequent mutation point was at position 91. CONCLUSIONS Amoxicillin, tetracycline and telithromycin were active against levofloxacin-resistant H. pylori and levofloxacin resistance was mainly due to point mutation in the gyrA gene, especially at amino acid position 91.
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Affiliation(s)
- Ching Ching Lee
- Department of Microbiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, SAR, China
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Bago P, Vcev A, Tomic M, Rozankovic M, Marusić M, Bago J. High eradication rate of H. pylori with moxifloxacin-based treatment: a randomized controlled trial. Wien Klin Wochenschr 2007; 119:372-8. [PMID: 17634896 DOI: 10.1007/s00508-007-0807-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2006] [Accepted: 01/16/2007] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Eradication of Helicobacter pylori remains a problematic treatment issue in clinical practice. The intention is to find a treatment that achieves a high rate of eradication at a low price and treatment options that are now used give us the opportunity to achieve this goal. Recently published results showing a low rate of resistance and better compliance with moxifloxacin-based treatment regimens indicate the need to investigate its efficacy in H. pylori eradication. This study is based on proving the efficacy of moxifloxacin in H. pylori eradication within the triple therapy. AIMS AND METHODS The aim of the study was to compare the efficacy of one week of moxifloxacin-based treatment with the standard treatment for H. pylori eradication. Patients with H. pylori infection and non-ulcer dyspepsia (n = 277) were randomly divided into four groups to receive: moxifloxacin 400 mg/d, metronidazole 400 mg twice daily, lansoprazole 30 mg twice daily (MML group); moxifloxacin 400 mg/d, amoxicillin 1 g twice daily, lansoprazole 30 mg twice daily (MAL group); clarithromycin 500 mg twice daily, metronidazole 400 mg twice daily, lansoprazole 30 mg twice daily (CML group); clarithromycin 500 mg twice daily, amoxicillin 1 g twice daily, lansoprazole 30 mg twice daily (CAL group). The patients were assessed for prevalence of H. pylori using the CLO test, histology and culture on gastric biopsy samples obtained during upper gastrointestinal endoscopy before randomization and 4-6 weeks after completion of treatment. Bacterial sensitivity to clarithromycin and moxifloxacin was determined with the E-test. RESULTS 265 (95.6%) patients completed the study forming the basis for PP analysis. Eradication rates of H. pylori in ITT and in PP analyses were: in the MML group 93.5% (58/62) and 96.7% (58/60), respectively; in the MAL group 86.4% (57/66) and 90.5% (57/63); in the CML group 70.4% (50/71) and 75.8% (50/66); and in the CAL group 78.2% (61/78) and 80.2% (61/76). Moxifloxacin treatment protocols were significantly more effective on both ITT and PP analyses than the clarithromycin based protocols with only one exception (MAL vs. CAL on ITT analysis). Among 238 patients (86% of the entire study group), strains showing primary resistance to clarithromycin were found in 10.8% and to moxifloxacin in 5.9%. Eradication of moxifloxacin sensitive/resistant strains was 98.1%/75% for MML (p < 0.01) and 91.1%/66.7% for MAL (p = n.s.); comparison of eradication of sensitive strains in MML and MAL regimens was 98.1%/91.1% (p < 0.05), and for resistant strains 75%/66.7% (p = n.s.). CML and CAL protocols did not differ in efficacy of eradication of clarithromycin sensitive or resistant strains. CONCLUSION Moxifloxacin-based triple therapies showed higher eradication rates with few side effects and good drug compliance when compared with standard H. pylori treatments. Moreover, the increased prevalence of clarithromycin resistance suggests that moxifloxacin-based regimens could be safe and effective options in treatment of H. pylori infection.
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Affiliation(s)
- Petra Bago
- Department of Gastroenterology, Internal Medicine Clinic, General Hospital Sveti Duh, Zagreb, Croatia
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Aydin A, Onder G, Akarca U, Tekin F, Tuncyurek M, Ilter T. Comparison of 1- and 2-week pantoprazole-based triple therapies in clarithromycin-sensitive and resistant cases. Eur J Intern Med 2007; 18:496-500. [PMID: 17822662 DOI: 10.1016/j.ejim.2007.02.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2006] [Revised: 11/25/2006] [Accepted: 02/09/2007] [Indexed: 12/15/2022]
Abstract
BACKGROUND The objectives of this prospective study were: (i) to compare the efficacy of 1-week with 2-week pantoprazole-based triple therapy and (ii) to evaluate the impact of clarithromycin resistance on Helicobacter pylori (H. pylori) eradication rates. METHODS Eighty dyspeptic patients were randomly allocated to two groups. The first group (PAC-1, n=40) received pantoprazole 40 mg, amoxicillin 1000 mg, and clarithromycin 500 mg twice a day for one week, and the second group (PAC-2, n=40) received the same regimen for two weeks. Endoscopy was repeated one month after the end of the treatment. RESULTS DNA extraction for clarithromycin resistance could not be performed in seven cases. Five cases were lost to follow-up. Clarithromycin resistance was found to be 44.1% (15/34) in the PAC-1 group and 58.8% (20/34) in the PAC-2 group (p>0.05). Eradication was achieved in 16 (PP: 47.1%, ITT: 44.4%) and 25 (PP:73.5%, ITT: 67.6%) patients in the PAC-1 and PAC-2 groups, respectively (p>0.05). H. pylori was eradicated in 4 of 15 (PP: 26.7%, ITT: 26.7%) clarithromycin-resistant patients in the PAC-1 group and in 12 of 20 (PP: 60%, ITT: 60%) clarithromycin-resistant patients in the PAC-2 group (p>0.05). Among the clarithromycin-sensitive ones, eradication was achieved in 12 of 19 (PP: 63.2%, ITT: 57.1%) patients in the PAC-1 group and in 13 of 14 (PP: 92.8%, ITT: 76.5%) patients in the PAC-2 group (p>0.05). CONCLUSION Although the 2-week regimen of pantoprazole-based triple therapy was effective for H. pylori eradication in clarithromycin-sensitive cases, highly effective H. pylori eradication protocols are needed for clarithromycin-resistant ones.
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Affiliation(s)
- Ahmet Aydin
- Ege University Medical School, Department of Gastroenterology, Izmir, Turkey
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Onder G, Aydin A, Akarca U, Tekin F, Ozutemiz O, Ilter T. High Helicobacter pylori resistance rate to clarithromycin in Turkey. J Clin Gastroenterol 2007; 41:747-50. [PMID: 17700422 DOI: 10.1097/mcg.0b013e31802e7ee7] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
GOALS To assess the resistance of Helicobacter pylori to clarithromycin in Turkey. BACKGROUND Recent studies have emphasized the remarkable reduction in H. pylori eradication rates. Resistance to clarithromycin is the most important factor affecting the success of H. pylori eradication therapies. STUDY The study involved 110 consecutive adult dyspeptic patients infected with H. pylori. Resistance to clarithromycin was studied by real-time polymerase chain reaction method on gastric biopsy specimens. RESULTS Of the 110 patients, 56 (50.9%) were male and mean age (+/-SD) was 45.1+/-13.1 years. Overall, 53 (48.2%) patients were found to be resistant to clarithromycin. Resistance to clarithromycin was not statistically associated with age, sex, previous macrolide use, residence (urban/rural), education status, and presence of peptic ulcer. CONCLUSIONS The rate of resistance to clarithromycin was found to be markedly high. This result may explain the recently reported low success rates of H. pylori eradication therapies with clarithromycin.
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Affiliation(s)
- Goktug Onder
- Department of Gastroenterology, Ege University Medical School, Izmir, Turkey
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Gisbert JP, Fernández-Bermejo M, Molina-Infante J, Pérez-Gallardo B, Prieto-Bermejo AB, Mateos-Rodríguez JM, Robledo-Andrés P, González-García G. First-line triple therapy with levofloxacin for Helicobacter pylori eradication. Aliment Pharmacol Ther 2007; 26:495-500. [PMID: 17635384 DOI: 10.1111/j.1365-2036.2007.03384.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND At present, the efficacy of proton pump inhibitor-clarithromycin-amoxicillin regimen is relatively low. AIM To evaluate the efficacy and tolerability of a first-line triple clarithromycin-free regimen including ranitidine bismuth citrate, levofloxacin and amoxicillin. DESIGN Prospective study. PATIENTS Helicobacter pylori-positive patients complaining of dyspeptic symptoms referred for gastroscopy. INTERVENTION Levofloxacin (500 mg b.d.), amoxicillin (1 g b.d.) and ranitidine bismuth citrate (400 mg b.d.) was prescribed for 10 days. OUTCOME Eradication was confirmed by a (13)C-urea breath test 8 weeks after therapy. Compliance with therapy was determined by questioning and the recovery of empty envelopes of medications. Incidence of adverse effects was evaluated by means of a specific questionnaire. RESULTS Sixty-four patients were included (30% peptic ulcer, 70% functional dyspepsia). Almost all (97%) patients took all the medications correctly. Per-protocol and intention-to-treat eradication rates were 88.5% (95% CI =78-95%) and 84.4 (74-91%). Adverse effects were reported in 9.5% of the patients, mainly including diarrhoea (7.9%); none of them were severe. CONCLUSION This new 10-day levofloxacin-based combination represents an alternative to clarithromycin-based therapy, as it meets the criteria set for regimens used as primary H. pylori treatment: effectiveness (>80%), simplicity (twice-daily dosing and excellent compliance) and safety (low incidence of adverse effects).
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Affiliation(s)
- J P Gisbert
- Gastroenterology Unit, Hospital Universitario de la Princesa, Madrid, Spain.
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48
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Kalach N, Serhal L, Asmar E, Campeotto F, Bergeret M, Dehecq E, Spyckerelle C, Charkaluk ML, Decoster A, Dupont C, Raymond J. Helicobacter pylori primary resistant strains over 11 years in French children. Diagn Microbiol Infect Dis 2007; 59:217-22. [PMID: 17662555 DOI: 10.1016/j.diagmicrobio.2007.05.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Revised: 04/28/2007] [Accepted: 05/06/2007] [Indexed: 01/06/2023]
Abstract
The yearly prevalence between 1994 and 2005 of primary resistance to amoxicillin, metronidazole, and clarithromycin of 377 Helicobacter pylori strains isolated from children was studied. All the H. pylori strains were susceptible to amoxicillin, 138/377 (36.7%) were resistant to metronidazole, 86/377 (22.8%) to clarithromycin, and 30/377 (7.9%) to both metronidazole and clarithromycin. Over the entire period, resistance to clarithromycin did not change, whereas metronidazole resistance decreased significantly from 43.3% (1994-1998) to 32% (1999-2005), P = 0.001.
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Affiliation(s)
- Nicolas Kalach
- Clinique de Pédiatrie Saint Antoine, Hôpital Saint Vincent de Paul, BD de Belfort, Université Catholique de Lille, 59020 Lille, France
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Abstract
Triple therapy, consisting of two antibiotics, clarithomycin and amoxicillin or metronidazole in combination with a proton pump inhibitor (PPI) has become the first-line option for infection with Helicobacter pylori and has been recommended at several consensus conferences. In clinical practice, approximately 20% of patients will fail to obtain H. pylori eradication with the recommended treatment regimens. Major causes of treatment failure are insufficient patient compliance and antibiotic resistance. Because of antibiotic resistance, bismuth-based quadruple therapy has also become a first-line regimen in areas with exceedingly high rates of clarithromycin and metronidazole resistance, and is the preferred second-line option otherwise. Triple therapies based on levofloxacin and/or rifabutin mainly with combination of amoxicillin are options if multiple eradication failure occurs. However, following therapy failure beyond a second treatment attempt requires antibiotic resistance testing. New drugs and adjuvant agents have been reported but their efficacy needs further evaluation.
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Affiliation(s)
- K Wolle
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Leipziger Str. 44, 39120 Magdeburg, Germany.
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Mégraud F, Lehours P. Helicobacter pylori detection and antimicrobial susceptibility testing. Clin Microbiol Rev 2007; 20:280-322. [PMID: 17428887 PMCID: PMC1865594 DOI: 10.1128/cmr.00033-06] [Citation(s) in RCA: 463] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The discovery of Helicobacter pylori in 1982 was the starting point of a revolution concerning the concepts and management of gastroduodenal diseases. It is now well accepted that the most common stomach disease, peptic ulcer disease, is an infectious disease, and all consensus conferences agree that the causative agent, H. pylori, must be treated with antibiotics. Furthermore, the concept emerged that this bacterium could be the trigger of various malignant diseases of the stomach, and it is now a model for chronic bacterial infections causing cancer. Most of the many different techniques involved in diagnosis of H. pylori infection are performed in clinical microbiology laboratories. The aim of this article is to review the current status of these methods and their application, highlighting the important progress which has been made in the past decade. Both invasive and noninvasive techniques will be reviewed.
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Affiliation(s)
- Francis Mégraud
- INSERM U853, and Université Victor Segalen Bordeaux 2, and Laboratoire de Bactériologie, Hôpital Pellegrin, Place Amélie Raba-Léon, 33076 Bordeaux cedex, France.
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