Sequential Therapy or Standard Triple Therapy for Helicobacter pylori Infection: An Updated Systematic Review. Am J Ther. 2016;23:e880-e893. [PMID: 25569598 DOI: 10.1097/mjt.0000000000000191]

Nanostructured proteins for delivering drugs to diseased tissues

During the last few years, nanostructures based on proteins have been playing a vital role in revolutionizing the nanomedicine era. Since protein nanoparticles are smaller and have a greater surface area, they retain a better capacity to interact with other molecules, resulting in carrying payloads efficiently to diseased tissues. Besides having attractive biocompatibility and biodegradability, protein nanoparticles can also be modified on their surfaces. For the fabrication of these nanostructures, there are several processes involved, including emulsification, desolvation, a combination of complex coacervation and electrospray. This can be achieved by using different proteins such as albumin, gelatin, elastin, gliadin, collagen, legumin and zein, as well as a combination of these proteins. It is possible to functionalize protein nanoparticles by altering their internal and external interfaces so that they can encapsulate drugs, release them in a controlled manner, disassemble them systematically and target tumors. This review highlights the physicochemical properties and engineering of several proteins to nano-dimensions used to deliver drugs to diseased tissues.

Current trends in <i>Helicobacter pylori</i> eradication therapy

According to the Maastricht VI consensus, the triple therapy (PPI + clarithromycin + amoxicillin) and bismuth-based quadruple therapy (PPI + bismuth + tetracycline + metronidazole) are considered and may be proscribed empirically as first-line regimens in the regions with low clarithromycin resistance rates (<15%). In the regions with high clarithromycin resistance rates (> 15%), as well as in the regions with unknown resistance to this antibacterial agent, it is recommended to use classical quadruple therapy with bismuth drugs as the main choice and quadruple therapy without bismuth drugs (“simultaneous” or “concomitant”) as an alternative. The second-line regimens of empiric choice (when antimicrobial susceptibility testing is not available) include fluoroquinolone-based quadruple therapy (PPI + levofloxacin + amoxicillin + bismuth) or fluoroquinolone-based triple therapy (PPI + levofloxacin + amoxicillin) and bismuth-based quadruple therapy. The Maastricht VI consensus regulates the use of rifabutin-based triple therapy (PPI + amoxicillin + rifabutin) as a “rescue” therapy, if the above ET schemes are ineffective and there is no possibility to conduct an antimicrobial susceptibility test. In its latest clinical guidelines, the Russian Gastroenterological Association (RGA) recommends with a view to achieving maximum treatment efficiency during classic triple ET and levelling the risk of further progression of clarithromycin resistance in Russia to take additional measures to increase its effectiveness (detailed instruction of a patient and control over strict adherence to the prescribed regimen, prolonging the course up to 14 days; prescribing PPI at increased dose twice a day; the latest generation PPIs (rabeprazole and esomeprazole); adding bismuth tripotassium dicitrate (240 mg 2 times a day) to the standard triple therapy; adding cytoprotector rebamipide (100 mg 3 times a day) to the standard triple therapy; adding a probiotic with proven efficacy to the standard triple therapy within controlled studies).

Effectiveness of Rebamipide as a part of the <i>Helicobacter pylori</i> eradication therapy in Russia: a meta-analysis of controlled trials

Aim. To perform a meta-analysis of the data on Rebamipide efficacy and safety as a part of Helicobacter pylori eradication therapy in Russian patients. Materials and methods. A search for original studies was conducted in the electronic database of the Russian Science Citation Index (RSCI) on the Scientific Electronic Library (SEL Elibrary.ru). Google (Google.com) was used for the "grey" search. All Russian controlled studies comparing the efficacy and/or safety of Rebamipide as a part of the regimen of H. pylori eradication therapy were included in the final analysis. Results. In 6 included controlled trials with a cumulative population (considering double comparisons between multiple groups) of 531 patients (273 in Rebamipide groups and 258 in groups without Rebamipide), the pooled eradication effectiveness was 90.376% (95% confidence interval CI 86.31193.560) in patients receiving Rebamipide and 81.681% (95% CI 76.49986.141) in patients receiving eradication regimens without Rebamipide. The meta-analysis showed that the Rebamipide addition to eradication regimens significantly improved efficacy (odds ratio 2.162, 95% CI 1.2683.685; p=0.005). No significant heterogeneity was found between study results (p=0.863; I2=0.00%); therefore, a fixed effects model was used in the resulting analysis. In addition, the meta-analysis of included studies showed a reduction of adverse events (odds ratio 0.569, 95% CI 0.3330.970) in the groups receiving Rebamipide; p=0.038). This effect of Rebamipide deserves special attention and requires additional study, as the result was at the border of statistical significance in the subanalysis of three studies with a large margin of risk reduction in one of them (with the largest sample of patients). Conclusion. The present meta-analysis demonstrated that the Rebamipide addition to H. pylori eradication regimens significantly improves the treatment effectiveness in the Russian patient population.

Herbal Medicines in the Treatment of Dyspepsia: An Overview

This review focuses on the efficacy of herbal medicines for managing dyspepsia in humans and animals. Searches were conducted on the PubMed, Science Direct, and Medline databases, for publications in the last 3 years. In each database, the search terms used consisted of the 2 key terms describing the disorder and subtypes plus each of the terms relating to the therapy. The key terms used were "natural product" and "medicinal plant" in a cross-over with "dyspepsia" and "functional dyspepsia" (i.e., gastroprotection, Helicobacter pylori infection, prokinetic). We included all human and animal studies on the effects of herbal medicines reporting the key outcome of dyspepsia symptoms. Preclinical studies using critically validated models showed that most medicinal plants with gastroprotective action had antioxidant, anti-inflammatory, anti-apoptotic, and antisecretory effects. Moreover, several species displayed anti Helicobacter pylori and prokinetic efficacy. The data availability of controlled clinical studies is currently minimal. The use of different methodologies and the minimal number of patients raise doubts about the effects of these preparations. Only adequate clinical trials with scientifically validated methods can determine whether different herbal medicines can be used as viable alternatives to the conventional pharmacological treatments used to control dyspepsia symptoms.

The Challenges of Eradicating Pediatric Helicobacter pylori Infection in the Era of Probiotics

Helicobacter pylori (H. pylori), the most common infection of childhood, results in life-threatening complications during adulthood if left untreated. Most of these complications are related to H. pylori-induced chronic inflammation. The dysbiosis caused by H. pylori is not limited to the gastric microenvironment, but it affects the entire gastrointestinal tract. Eradication of H. pylori has recently become a real challenge for clinicians due to both the persistent increase in antibiotic resistance worldwide and the wide spectrum of side effects associated with the eradication regimens resulting; therefore, there is an urgent need for more effective and less noxious treatment options. Thus, probiotics might be a promising choice in both adults and children with H. pylori infection since their role in improving the eradication rate of this infection has been proved in multiple studies. The positive effects of probiotics might be explained by their abilities to produce antimicrobial compounds and antioxidants, alter local gastric pH, and subsequently decrease H. pylori colonization and adherence to gastric epithelial cells. Nevertheless, if used alone probiotics do not considerably increase the eradication rate.

Response of Helicobacter Pylori Eradication Treatment in Patients With Normal and Below-Normal Serum Vitamin D Levels

Introduction

 The infection of Helicobacter pylori (H. pylori) is affected by the host immune system and the genetic makeup. It is postulated that deficiency of vitamin D may interfere in normal immunological response to infectious agents, including H. pylori, and increase the risk of infection. This study aims to find the relationship between vitamin D status in the body and patient’s response to H. pylori eradication treatment.

Methods

 One hundred and fifty patients (n = 150) between the ages of 18 and 60 years of either gender, diagnosed with H. pylori, were included in the study. After enrollment, patients were started on first-line eradication therapy, which included omeprazole, amoxicillin, and clarithromycin for 14 days. Patient’s vitamin D levels were tested via laboratory. After 14 days, patients' stools were tested for presence of H. pylori antigen. 

Results

 A total of 128 participants completed the study, out of which 92 (71.8%) participants showed no H. pylori antigen in stool after 14 days and 36 (28.1%) participants still showed H. pylori in their stool. The mean serum vitamin D level was significantly higher in participants who had successful treatment compared to those who had unsuccessful treatment (31.01 ± 7.8 ng/mL vs. 18.9 ± 5.6 ng/mL; p-value < 0.0001).

Conclusion

 Vitamin D levels may affect the response of H. pylori eradication therapy. Further large-scale studies are needed in which vitamin D is given as an intervention to further study the association between vitamin D levels and H. pylori treatment response. 

Anti-inflammatory and anti-oxidative effect of Korean propolis on Helicobacter pylori-induced gastric damage in vitro

Helicobacter pylori, present in the stomach lining, is a Gramnegative bacterium that causes various gastrointestinal diseases, including gastritis and peptic ulcers. Propolis is a natural resinous substance collected from a variety of plants, and contains several natural bioactive substances. The aim of this study was to investigate the anti-inflammatory and antioxidative effects of Korean propolis on H. pylori-induced damage in the human adenocarcinoma gastric cell line. The propolis used in this study was obtained from the Korea Beekeeping Association in South Korea. The expression of pro-inflammatory interleukins (ILs), such as IL-8, IL-12, IL-1β, tumor necrosis factor alpha, cyclooxygenase-2, and inducible nitric oxide synthase, which was increased after H. pylori infection, significantly decreased in a dose-dependent manner upon pretreatment with Korean propolis, because of the suppression of mitogen-activated protein kinases and nuclear factor kB pathway. The anti-oxidative activity of propolis was assessed using the 2,2-diphenyl-1-picrylhydrazyl hydrate free radical assay. Korean propolis showed significant anti-oxidative effects via reactive oxygen species scavenging. In addition, pretreatment with Korean propolis upregulated the expression of anti-oxidant enzymes through Nrf2 signaling activation. These findings indicate that the use of Korean propolis, which has anti-inflammatory and anti-oxidative effects, can be promising for the prevention of H. pylori-induced gastric damage.

Efficiency of the Inclusion of Rebamipide in the Eradication Therapy for Helicobacter pylori Infection: Meta-Analysis of Randomized Controlled Studies

BACKGROUND

There has been a negative trend in the effectiveness of classic eradication therapy regimens for Helicobacter pylori (H. pylori), which has largely been determined from the emergence and spread of antibiotic resistance. Several studies have shown that adding rebamipide to eradication regimens leads to an increase in the effectiveness of treatment.

AIM

To evaluate the efficacy and safety of including rebamipide in the eradication regimens for H. pylori infection.

METHODS

The literature search was conducted in the MEDLINE/PubMed, EMBASE, Cochrane Central Register, Korean Medical Citation Index, and Russian Science Citation Index databases. All identified randomized controlled trials comparing rebamipide supplementation with non-rebamipide-containing eradication regimens for the treatment of H. pylori infection were included in the final analysis.

RESULTS

We identified 11 randomized controlled trials (RCTs) involving 1227 patients (631 in groups with rebamipide and 596 in groups without rebamipide). The meta-analysis showed that the addition of rebamipide to eradication regimens significantly increased the effectiveness of treatment (odds ratio (OR) 1.753, 95% confidence interval (CI) 1.312-2.333, p < 0.001). The subgroup analysis demonstrated that rebamipide significantly increased the effectiveness of eradication when added to a dual therapy regimen (OR 1.766, 95% CI: 1.167-2.495, p = 0.006); however, no significant improvement in effectiveness was observed when it was added to the triple therapy regimen (OR 1.638, 95% CI 0.833-3.219, p = 0.152).

CONCLUSION

This meta-analysis demonstrated that the addition of rebamipide to H. pylori eradication regimens significantly increases the effectiveness of treatment.

Multidrug resistance in Helicobacter pylori: current state and future directions

Introduction: Helicobacter pylori antibiotic resistance has increased worldwide and multidrug resistance (MDR), which seriously hampers eradication success of the frequent chronic infection, has often been reported. Areas covered: H. pylori MDR rates are discussed, mostly from recent articles published since 2015. Present approaches and future directions to counteract the MDR are outlined. Expert opinion: Alarming presence of triple, quadruple and, in some studies, quintuple and sextuple resistance was detected. Primary MDR rates ranged from <10% in most European countries to >40% in Peru. Post-treatment or overall MDR rates were >23-36% in about half of the studies. MDR prevalence has varied both among and within the countries. Factors linked to the MDR are national antibiotic consumption, antibiotic misuse, treatment failures and bacterial factors such as mutations, efflux pumps, and biofilms. Important directions to counteract the MDR increase can be optimization of present and new eradication regimens, wider use of bismuth-containing regimens, assessment of benefit of vonoprazan, new antibiotics such as newer fluoroquinolones and oxazolidinone analogues, adjuvants involving N-acetylcysteine and probiotics, anti-biofilm approaches using anti-biofilm peptides and rhamnolipid and development of vaccines and non-invasive tests for resistance detection. However, more efforts and studies are required. Strain susceptibility testing is increasingly important.

[The efficacy and safety of quadruple therapy without bismuth (concomitant therapy) in the treatment of patients with Helicobacter pylori - associated gastric and duodenal peptic ulcer disease]

AIM

Evaluation of the efficacy and safety of quadrupletherapy without bismuth (concomitant therapy) in patients with Helicobacter pylori - associated gastric ulcer and duodenal ulcer in the framework of a comparative research in the population of patients in Russia.

MATERIALS AND METHODS

A prospective randomized trial was conducted, which included 210 patients with H. pylori - associated gastric/duodenal ulcer without complications. During the process of randomization, the patients were divided into three equal groups (n=70) depending on the prescribed 10-day scheme of eradication therapy (ET): the first group received the classic triple scheme (Omeprazole 20 mg 2 times a day, Amoxicillin 1000 mg 2 times a day and Clarithromycin 500 mg 2 times a day); the second group received quadruple therapy with bismuth drugs (Omeprazole 20 mg 2 times a day, Tetracycline 500 mg 4 times a day, Metronidazole 500 mg 3 times a day, Bismuth subcitrate potassium 120 mg 4 times a day); the third group received quadruple therapy without bismuth - concomitant therapy (Omeprazole 20 mg 2 times a day, Amoxicillin 1000 mg 2 times a day, Clarithromycin 500 mg 2 times a day and Metronidazole 500 mg 2 times a day). Diagnostics of H. pylori infection during screening and control of eradication was carried out via the fast urease biopsy sample test and urea breath test system. Control of the effectiveness of ET of the microorganism was carried out not earlier than 4 weeks after the end of the treatment. During the course of therapy, the frequency of development of side effects was assessed using a special questionnaire.

RESULTS AND DISCUSSION

The effectiveness of triple therapy was 72.8% (ITT; 95% CI of 62.17-83.54) and 78,4% (PP; 95% CI 68.19-88.72); quadruple therapy with the preparation of bismuth - 80.0% (ITT; 95% CI 70.39-89.6) and 84,8% (PP; 95% CI, 75.96-93.73); quadruple therapy without bismuth - concomitant therapy - 84.2% (ITT; 95% CI 75.54-93.02) and 92.1% (PP; 95% CI 85.43-98.94). Quadruple therapy without bismuth was reliably more effective than the classical triple therapy in the PP selection (p=0.044883). Statistical analysis showed a tendency to poorer effectiveness of ET in patients who had previously used antibiotic therapy (OR 0.4317; 95% CI 0.1776-1.049), and in individuals with a rapid metabolism genotype - CYP2C19*1/*1 (OR 0.12; 95% CI 0.005848-2.4624). The frequency of development of side effects during the use of triple therapy was 18.5% (95% CI of 9.23-27.91), when using quadruple therapy with bismuth - 20.0% (95% CI 10.39-29.6), and with the use of quadruple therapy without bismuth - concomitant therapy - 24.2% (95% CI 13.98-34.58).

CONCLUSION

This prospective randomized study demonstrated the high efficiency of quadruple therapy without bismuth (concomitant therapy) in the framework of eradication of H. pylori infection in Russia.

Predictors of triple therapy treatment failure among H. pylori infected patients attending at a tertiary hospital in Northwest Tanzania: a prospective study

BACKGROUND

Helicobacter pylori (H.pylori) infection is a common medical problem in resource limited areas. The treatment outcome after triple therapy has not been well studied in developing countries and preliminary data suggests a high rate of treatment failure. This study investigated the triple therapy treatment failure rate and associated factors among dyspeptic patients receiving H. pylori first line therapy at a tertiary hospital, Tanzania.

METHODS

A prospective study in the Gastroenterology unit of the Bugando Medical Centre (BMC) was conducted between October 2015 and May 2017. All dyspeptic patients with stool antigen tests positive for H.pylori were given first line therapy, and stool antigen testing was repeated within 7 days and 5 weeks after completion of the treatment. Biopsies were taken before initiation of therapy and analysed for clarithromycin and quinolone resistance mutations using polymerise chain reaction (PCR) and sequencing. Adherence and other social-demographic characteristics were documented.

RESULTS

A total of 210 patients were enrolled; the median age was 35 years (interquartile range, 27-48). First line treatment failure as defined by positive stool antigen 5 weeks post treatment was observed in 65/210 (31%) of patients. Independent predictors of first line treatment failure were presence of clarithromycin resistance mutations (OR: 23.12, 95% CI (9.38-56.98), P < 0.001) and poor adherence (OR: 7.39, 95% CI (3.25-16.77), P < 0.001). The sensitivity and specificity of stool antigen testing within 7 days after completion therapy in detecting treatment failure was 100 and 93.2%, respectively.

CONCLUSION

Nearly one-third of patients with clarithromycin resistance mutations and poor adherence develop first line treatment failure. Routine stool antigen testing within seven days after completion of therapy can be considered in order to initiate second line treatment early to prevent associated morbidities.

Herbal medicine as an auspicious therapeutic approach for the eradication of Helicobacter pylori infection: A concise review

Helicobacter pylori (H. pylori) causes gastric mucosa inflammation and gastric cancer mostly via several virulence factors. Induction of proinflammatory pathways plays a crucial role in chronic inflammation, gastric carcinoma, and H. pylori pathogenesis. Herbal medicines (HMs) are nontoxic, inexpensive, and mostly anti-inflammatory reminding meticulous emphasis on the elimination of H. pylori and gastric cancer. Several HM has exerted paramount anti-H. pylori traits. In addition, they exert anti-inflammatory effects through several cellular circuits such as inhibition of 5'-adenosine monophosphate-activated protein kinase, nuclear factor-κB, and activator protein-1 pathway activation leading to the inhibition of proinflammatory cytokines (interleukin 1α [IL-1α], IL-1β, IL-6, IL-8, IL-12, interferon γ, and tumor necrosis factor-α) expression. Furthermore, they inhibit nitrous oxide release and COX-2 and iNOS activity. The apoptosis induction in Th1 and Th17-polarized lymphocytes and M2-macrophagic polarization and STAT6 activation has also been exhibited. Thus, their exact consumable amount has not been revealed, and clinical trials are needed to achieve optimal concentration and their pharmacokinetics. In the aspect of bioavailability, solubility, absorption, and metabolism of herbal compounds, nanocarriers such as poly lactideco-glycolide-based loading and related formulations are helpful. Noticeably, combined therapies accompanied by probiotics can also be examined for better clearance of gastric mucosa. In addition, downregulation of inflammatory microRNAs (miRNAs) by HMs and upregulation of those anti-inflammatory miRNAs is proposed to protect the gastric mucosa. Thus there is anticipation that in near future HM-based formulations and proper delivery systems are possibly applicable against gastric cancer or other ailments because of H. pylori.

Helicobacter pylori therapy and clinical perspective

Helicobacter pylori induces chronic gastritis and duodenal ulcer in a small fraction of the colonised population. Three decades after the discovery of H. pylori and disclosure of an urgent need for eliminating the bacterium in patients, it seems that we are still in the first steps of dealing with this mysterious organism. Treatment of H. pylori is a complex dilemma for clinicians, a repeating sentence by many scientists who spend years on this research topic. Apart from many modifications in initial first-line treatment of H. pylori, gastroenterologists are unable to overcome the problem of therapeutic failure. Choosing the best regimen in any region depends on many factors, which have been the focus of many randomised clinical trials. A potential increase in efficacy of future therapies may be influenced by adding the novel potassium-competitive acid blocker vonoprazan. Undeniably, in-depth analysis is necessary to propose more effective therapeutic regimens. Meanwhile, we recommend the performance of antimicrobial susceptibility testing before any antimicrobial prescription.

Evaluation of the efficacy and safety of the hybrid scheme for eradication therapy of Helicobacter pylori infection

AIM

The aim is to conduct a comprehensive comparative study of the efficacy and safety of the hybrid scheme of eradication therapy (ET) in patients with peptic ulcer of the stomach or duodenum associated with Helicobacter pylori.

MATERIALS AND METHODS

Materials and methods. In a prospective, randomized comparative study, 180 patients were divided into three equal groups of 60 people, depending on the prescribed 10-day ET regimen. Group 1 - the standard triple scheme (omeprazole, amoxicillin and clarithromycin); group 2 - four-component therapy with preparations of bismuth (omeprazole, tetracycline, metronidazole, bismuth tricalium dicitrate); group 3 - hybrid scheme (first 5 days: omeprazole and amoxicillin, the next 5 days: omeprazole, amoxicillin, clarithromycin, metronidazole). The effectiveness of ET was determined with the help of a breath test a month after the end of therapy. Adverse events were recorded by patients in specially developed diaries. Pharmacoeconomic analysis was carried out using the "cost-effectiveness" method with calculation of the CER coefficient.

RESULTS

Results and discussion. The effectiveness of standard triple therapy was 73.3% (ITT), 75.9% (PP); four-component therapy with bismuth preparations - 78.3% (ITT), 82.4% (PP); hybrid scheme - 85% (ITT), 91% (PP). Hybrid therapy proved to be significantly more effective than standard triple therapy with a odds ratio (OR) of 3.25; 95% confidence interval (CI) 1.08-9.73 (p=0.043, χ2=4.75, p-level=0.029298). The incidence of adverse events with the use of triple, four-component and hybrid ET regimens was 15; 18.3 and 28.3% respectively. The OR of at least one adverse event in patients receiving a hybrid ET regimen compared with triple therapy was 2.24 (95% CI 0.91-5.53, p=0.0823, χ2=3.14, p-level=0.076394), and compared with the four-component therapy - 1.76 (95% CI 0.74-4.17, p=0.2804, χ2=1.68, p-level=0.194924). According to the results of the pharmacoeconomic analysis, the most profitable from an economic point of view was a hybrid ET scheme with a CER of 20.1.

CONCLUSION

The conclusion. Hybrid therapy showed the greatest effectiveness in comparison with the triple and four-component ET regimens, however, the incidence of side effects in patients receiving the hybrid ET scheme was higher, although it remained within the acceptable level for use in clinical practice. Pharmacoeconomic analysis also showed the advisability of designating a hybrid ET scheme. The obtained data allow to draw a conclusion about the necessity of further study of the efficiency and safety of the hybrid ET scheme.

The effect of vitamin D deficiency on eradication rates of Helicobacter pylori infection

Background/Aim

Many studies have investigated risk factors other than antibiotic resistance linked to Helicobacter pylori (H. pylori) eradication failure. The aim of this study was to study the effect of serum levels of 25‐hydroxy‐vitamin D (25[OH]D) on eradication rates of H. pylori infection.

Methods

This study included 150 patients diagnosed with H. pylori gastritis using magnifying narrow‐band imaging endoscopy supported by stool antigen test. Serum 25‐OH vitamin D levels were measured via the Enzyme‐Linked Immune Sorbent assay (ELISA) method before starting eradication therapy of H. pylori infection. All patients were treated with clarithromycin‐based triple therapy for 14 days. H. pylori eradication was determined via a stool antigen test performed 4 weeks after the end of therapy. According to the serum level of 25‐OH vitamin D levels, the patients were divided into two groups: group I (sufficient) had a vitamin D level of ≥20 ng/mL, while group II (deficient) had a vitamin D level of <20 ng/mL.

Results

Our results revealed that eradication was successful in 105 (70%) patients and failed in 45 (30%) patients. The mean 25[OH]D level was significantly lower in the eradication failure group compared to the successful treatment group (14.7 ± 4.5 vs 27.41 ± 7.1; P < 0.001). Furthermore, there were significantly more patients with deficient 25[OH]D levels in the failed treatment group, 30 (66.6%), compared to the successful group, 10 (9.5%) (P < 0.001).

Conclusions

Our results demonstrated that 25‐OH vitamin D deficiency may be considered a risk factor related to eradication failure of H. pylori infection. In addition, a further randomized trial to evaluate the effect of vitamin D supplementation in H. pylori eradication is mandatory.

Natural Products for the Prevention and Management of Helicobacter pylori Infection

Helicobacter pylori is the main pathogen that induces chronic gastritis, peptic ulcers, atrophic gastritis, and other gastric disorders, and it is classified as a group I carcinogen. To eradicate H. pylori infection, triple therapy consisting of two antibiotics and a proton pump inhibitor is the most widely recommended first-line therapeutic strategy. Antimicrobial resistance to antibiotics contained in triple therapy could lead to therapeutic regimen failures. Recent studies showed that many natural products, including fruits, vegetables, spices, and medicinal plants, possess inhibitory effects on H. pylori, indicating their potential to be alternatives to prevent and manage H. pylori infection. This review summarizes the effects of natural products on H. pylori infection and highlights the mechanisms of action.

Helicobacter pylori treatment: antibiotics or probiotics

Treatment of Helicobacter pylori infection is important for the management of gastrointestinal disorders such as peptic ulcer and gastric cancer. Due to the increase in the prevalence of H. pylori resistance to antibiotics, triple therapy with clarithromycin is no longer the best treatment for H. pylori, especially in some areas where the local resistance to this antibiotic is higher than 20%. Alternative treatments have been proposed for the eradication of H. pylori. Some of them including novel antibiotics or classical ones in different combinations; these treatments are being used in the regular clinical practice as novel and more effective treatments. Others therapies are using probiotics associated to antibiotics to treat this infection.The present article is a revision of H. pylori eradication treatment, focusing on emerging approaches to avoid the treatment failure, using new therapies with antimicrobials or with probiotics.

Treatment of Helicobacter pylori infection 2017

This review summarizes important studies regarding Helicobacter pylori therapy published from April 2016 to April 2017. The main themes that emerge involve studies assessing the efficacy of bismuth and nonbismuth quadruple regimens. While in recent years, much of the emphasis on the use of bismuth has focussed on its utility in a second-line setting, an increasing number of studies this year have shown excellent efficacy in first-line therapy. The efficacy of bismuth as a second-line after sequential and concomitant therapy was particularly noteworthy. Antibiotic resistance was more intensely studied this year than for a long time, and definite trends are presented regarding an increase in resistance, including the fact that clarithromycin resistance in particular is now at a level where the continued use of clarithromycin triple therapy first-line as a mainstream treatment is not recommended. Another exciting trend to emerge this year is the utility of vonoprazan as an alternative to PPI therapy, especially in resistant and difficult-to-treat groups.

Helicobacter pylori prevalence and clinical significance in patients with quiescent Crohn's disease

Background

Helicobacter pylori (HP) infection is present in about 50% of the global population, and is associated with chronic gastritis, peptic disease and gastric malignancies. HP prevalence in Crohn’s disease (CD) patients was shown to be low compared to the general population, and its influence on disease activity is yet to be determined. Our aims were to determine the prevalence of HP in a selected group of CD patients with quiescent disease, and to assess the influence of its eradication on disease activity and endoscopic and laboratory activity measures.

Methods

Consecutive CD patients with quiescent disease underwent meticulous disease evaluation with MR enterography (MRE), video capsule endoscopy (VCE), CRP, fecal calprotectin and CDAI. All patients were tested for the presence of HP using stool antigen detection kit. Patients infected with HP were offered eradication treatment with sequential therapy. HP eradication was confirmed using urease breath test and stool antigen test. The influence of HP eradication on disease activity was assessed.

Results

Out of 56 patients enrolled, six patients (10.7%) had HP infection. Of them, five patients had gastro- duodenitis per VCE. All HP positive patients were offered eradication treatment and underwent successful eradication. Notably, 23 (50%) of patients had proximal disease per VCE, most of them (78%) were HP negative.

CDAI, CRP, fecal calprotectin and VCE Lewis inflammatory score did not change significantly following HP eradication, Gastric findings on VCE were not impacted by HP eradication.

Conclusions

The prevalence of HP infection in patients with quiescent CD is relatively low. Eradication of the bacteria did not significantly change neither disease activity measures nor the presence of gastro- duodenitis per VCE, suggesting it might be part of proximal CD. The influence of HP on CD activity merits further investigation.

Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report

Important progress has been made in the management of Helicobacter pylori infection and in this fifth edition of the Maastricht Consensus Report, key aspects related to the clinical role of H. pylori were re-evaluated in 2015. In the Maastricht V/Florence Consensus Conference, 43 experts from 24 countries examined new data related to H. pylori in five subdivided workshops: (1) Indications/Associations, (2) Diagnosis, (3) Treatment, (4) Prevention/Public Health, (5) H. pylori and the Gastric Microbiota. The results of the individual workshops were presented to a final consensus voting that included all participants. Recommendations are provided on the basis of the best available evidence and relevance to the management of H. pylori infection in the various clinical scenarios.

[Molecular genetic predictors of resistance to anti-Helicobacter pylori therapy]

In current clinical practice, there is no optimal empirical therapy for Helicobacter pylori (H. pylori) infection and there is a progressive decrease in the efficiency of classical eradication therapy (ET) regimens. The variability in the efficiency of ET in a specific patient is largely due to the heterogeneous molecular genetic mechanisms underlying the resistance of the microorganism to the components of the treatment regimens. The basis of the mechanisms for antibiotic resistance in H. pylori is mainly the point mutations in some genes, which determine alterations in the mechanisms of action of drugs, such as clarithromycin (domain V of 23S rRNA), metronidazole (rdxA, frxA), amoxicillin (pbp1A), tetracycline (16S rRNA), and levofloxacin (gyrA). The predictors of resistance to ET are also the CagA-negative status of the microorganism and the presence of the vacA s2 allele. There are a number of host genetic determinants (the CYP2C19 genotype (*1/*1, *1/*17, *17/*17) and the MDR1 3435 T/T genotype (in an Asian population)) that reduce the efficiency of ET, by altering the pharmacokinetics of proton pump inhibitors. In addition, the IL-1β-511 C/C polymorphism that affects gastric acid secretion is a predictor of the inefficiency of ET.

IV Spanish Consensus Conference on Helicobacter pylori infection treatment

Helicobacter pylori approximately infect 50% of Spanish population and causes chronic gastritis, peptic ulcer and gastric cancer. Until now, three consensus meetings on H.pylori infection had been performed in Spain (the last in 2012). The changes in the treatment schemes, and the increasing available evidence, have justified organizing the IVSpanish Consensus Conference (March 2016), focused on the treatment of this infection. Nineteen experts participated, who performed a systematic review of the scientific evidence and developed a series of recommendation that were subjected to an anonymous Delphi process of iterative voting. Scientific evidence and the strength of the recommendation were classified using GRADE guidelines. As starting point, this consensus increased the minimum acceptable efficacy of recommended treatments that should reach, or preferably surpass, the 90% cure rate when prescribed empirically. Therefore, only quadruple therapies (with or without bismuth), and generally lasting 14 days, are recommended both for first and second line treatments. Non-bismuth quadruple concomitant regimen, including a proton pump inhibitor, clarithromycin, amoxicillin and metronidazole, is recommended as first line. In the present consensus, other first line alternatives and rescue treatments are also reviewed and recommended.

Current status of Helicobacter pylori infection and evolution of treatment strategy in China

Infection with Helicobacter pylori (H. pylori) has become a common digestive disease and the prevalence of H. pylori infection remains high in the Chinese population. Recently, the Kyoto global consensus report on H. pylori gastritis and the Toronto consensus for the treatment of H. pylori infection in adults were issued. Therefore, it is essential to discuss the prevention and control of H. pylori infection in China. Due to severe resistance to antibiotics, toxic and host factors, the eradication rate in China has currently became lower than before. Therefore, whether to intervene H. pylori infection in the asymptomatic population and enlarge the indication for eradication and the cost-effect for this new strategy should be discussed. In addition, the implementation of the "test and treat" policy or not in China is debatable. Developing optimal treatment strategy has become a major challenge that clinicians face. This review focuses on the current H. pylori infection situation and the evolution of treatment strategies in China.

[The efficiency and safety of anti-Helicobacter pylori therapy in patients with concomitant chronic hepatitis C]

AIM

To evaluate the efficiency and safety of two eradication therapy (ET) regimens for Helicobacter pylori infection in patients with concomitant chronic hepatitis C (CHC) in relation to the stage of liver fibrosis (LF).

MATERIALS AND METHODS

A prospective clinical trial was conducted in parallel groups. Group 1 included 50 HCV-negative patients with H. pylori-associated peptic ulcer of the stomach or duodenum; Group 2 consisted of 50 HCV-positive patients with H. pylori-associated peptic ulcer of the stomach or duodenum concurrent with CHC. Each group was divided in 2 subgroups according to the used triple ET (a proton pump inhibitor (PPI) in a standard dose + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily for 10 days) or sequential therapy (PPI in a standard dose + amoxicillin 1000 mg twice daily within the first 5 days and then PPI in a standard dose + clarithromycin 500 mg twice daily + metronidazole 500 mg twice daily for the next 5 days). LF was assessed using indirect elastometry. The efficiency of ET was evaluated by a breath test (after 4 weeks) and an analysis depending on intention-to-treat (ITT) and per-protocol (PP) treatments. A patients recorded adverse events in specially developed diaries.

RESULTS

The efficiency of ET was 74% (ITT) and 80.4% (PP) in Group 1 and 76 (ITT) and 79.1% (PP) in Group 2. Both groups displayed a tendency towards an 11.9-12.4% increase in the efficiency of the sequential therapy versus the classical triple (PP) one. The rate of totally found side effects was 20% in Group 1 and 28% in Group 2. During sequential therapy, the rate of side effects was lower than that during the classical one. The efficiency of ET did not significantly depend on the stage of LF. Only the presence of concomitant type 2 diabetes mellitus and the use of macrolides (12 months before treatment) significantly lowered the efficiency of ET (OR 0,21; 95% CI 0,06-0,69, p=0,0102 and OR 0,27 95% CI 0,08-0,9, p=0,0342). LF regardless of its magnitude significantly determined the risk of adverse events during ET (OR 3,33 95% CI 1,19-9,31, p=0,0217). A group at the highest risk of adverse events included patients with liver cirrhosis (OR 4,87; 95% CI 1,01-23,5, p=0,0492).

CONCLUSION

It is appropriate to prescribe a sequential ET regimen as more effective and safe for patients with concomitant CHC during therapy for H. pylori infection-associated diseases. LF increases the risk of adverse events during ET.

Helicobacter pylori treatment: Still a work in progress

Helicobacter pylori is a common worldwide bacterium, possessing adaptability that has created difficulty achieving eradication. While the standard treatment was thought to be triple therapy with a proton pump inhibitor, amoxicillin, and clarithromycin, growing rates of treatment failure and antibiotic resistance have stimulated research into novel regimens. Quadruple therapy with bismuth has been compared for both first- and second-line treatments, but eradication still has not reached expected goals. Innovative regimens including sequential and concomitant therapy, as well as the introduction of new antibiotics into previous treatment schedules, have shown promising improvements in eradication rates. We discuss and compare these unique regimens, reviewing the current literature to deduce those which are most likely to provide the highest success in curing H. pylori infection.

Treatment of Helicobacter pylori Infection 2015

Many interesting articles have been published from many parts of the world over the last year assessing different issues around Helicobacter pylori eradication therapy. This article will address the published literature over the last year pertaining to the topic of treatment of H. pylori infection. The main themes that emerge are assessing the efficacy of standard triple therapy, as well as exploring new first-line treatments, mainly optimized nonbismuth- and bismuth-containing quadruple therapies with some promising data also emerging on dual therapy. There was also considerable progress in investigating antibiotic resistance rates with much more data emerging from varied parts of the world compared to recent years. There have also been advances in the use of adjunctive therapies, especially probiotic therapies. Undoubtedly, the eradication of H. pylori remains a worthwhile goal to alleviate the burden of diseases caused by the complications of this infection, including dyspepsia, peptic ulcer disease, and gastric cancer.

Effect of bacterial and host factors on Helicobacter pylori eradication therapy

INTRODUCTION

A clearer understanding of the factors affecting the cure rate of Helicobacter pylori infection might lead to the development of novel prevention strategies and therapeutic targets.

AREAS COVERED

This review covers two important issues that affect the eradication of H. pylori: bacterial and host factors. Several virulence factors have been shown to be predictors for gastroduodenal diseases. Successful treatment of H. pylori infection also depends on host genetic factors such as CYP2C19 and IL-1B. The latest evidence on host genetic factors is discussed.

EXPERT OPINION

The authors identify three main targets for achieving effective eradication therapy. The first therapeutic target is to identify counter measures for antibiotic-resistant H. pylori strains. Thus, antibiotic susceptibility should be checked in all patients, ideally, before the start of eradication treatment. The second therapeutic target is the inhibition of acid suppression. Maintaining a high intragastric pH for 24 h increases the effectiveness of some antibiotics and the eradication effects for H. pylori. The third therapeutic target is to identify high-risk groups; the CYP2C19 and IL-1B polymorphisms are candidates for significant risk factors. A personalized medical approach will likely increase the cure rate of H. pylori infection.