Efficacy and safety of bismuth-based quadruple therapy for Helicobacter pylori eradication in children

Efficacy of Bismuth Therapy in Eradicating Helicobacter pylori in Children-Data From the RENIHp Registry

OBJECTIVES

To evaluate the efficacy of colloidal bismuth subcitrate (CBS) therapy for the eradication of H. pylori in patients from a national pediatric registry of H. pylori infection.

METHODS

The Spanish Registry of Children with H. pylori Infection (RENIHp) is a national, multi-center, prospective, non-interventional registry that includes children aged 5-18 years with H. pylori infection diagnosed by endoscopy. All patients in the registry who were treated with CBS between the period 2020 and 2023 were included in this study. The primary outcome was the eradication rate, which was assessed using a 13C-urea breath test or monoclonal antigen in the stool 6-8 weeks post-treatment.

RESULTS

The registry included 682 patients, 38 (5.6%) of whom underwent treatment with CBS. Fifty percent (19/38) of patients had previously undergone unsuccessful eradication treatment. In 78.9% (30/38) of patients, treatment was guided by an antibiotic sensitivity test. In the remaining patients, an empirical approach was employed. The CBS therapies used were as follows: quadruple therapy with proton pump inhibitors (PPIs), CBS, amoxicillin, and metronidazole (MET) [18/38 (47.3%)]; quadruple therapy with PPIs, CBS, tetracycline, and MET [13/38 (34.2%)]; and other therapies [7/38 (18.4%)]. Thirty-two patients (84.2%) treated with CBS were followed-up with eradication monitoring. The overall eradication rate in patients treated with CBS was 93.8% (30/32, [95% CI: 85.4%-100%]), whereas it was 86.7% in patients in the registry who were not on CBS treatment (430/496, [95% CI: 83.3%-89.5%], p = 0.208). In the six patients with dual resistance to clarithromycin (CLA) and MET who were treated with quadruple therapy with CBS, the eradication rate was 100% (n = 6/6, [95% CI: 61.0%-100%]).

CONCLUSION

CBS therapies in our registry, although only used in selected cases and at lower than recommended levels, were very effective and showed an eradication rate of > 90%.

Updated joint ESPGHAN/NASPGHAN guidelines for management of Helicobacter pylori infection in children and adolescents (2023)

BACKGROUND

Evolving epidemiological data and increasing antibiotic resistance mandate an update of the European and North American Societies of Pediatric Gastroenterology, Hepatology and Nutrition guidelines.

METHODS

Certainty of evidence and strength of recommendations were rated by experts according to the Grading of Recommendation Assessment, Development, and Evaluation approach. PICO (patient population, intervention, comparator, and outcome) questions were developed and voted on by the group. Recommendations were formulated using the Evidence to Decision framework.

RESULTS

The current literature supports many of the previous recommendations and several new recommendations. Invasive testing with strain antimicrobial susceptibility analysis is recommended for the diagnosis and selection of eradication therapy for H. pylori infection. Molecular methods are acceptable for detection of infection and of antibiotic resistance in gastric biopsy specimens. Reliable, noninvasive tests can be used as a screening method for children with history of gastric cancer in a first-degree relative. When investigating causes of chronic immune thrombocytopenic purpura, testing for H. pylori is no longer recommended. When investigating other diseases such as inflammatory bowel disease, celiac disease, or eosinophilic esophagitis, specific diagnostic biopsies for H. pylori infection are not indicated. However, if H. pylori is an incidental finding, treatment may be considered after discussing the risks and benefits. Treatment should be based on antibiotic antimicrobial susceptibility testing and, if unavailable, regimens containing clarithromycin should be avoided.

CONCLUSIONS

Due to decreasing prevalence of infection, increasing challenges with antibiotic resistance, and emerging evidence regarding complications of infection, clinicians must be aware of these recommended changes to appropriately manage H. pylori infection and its clinical sequelae in children.

Microparticles and nanoparticles-based approaches to improve oral treatment of Helicobacter pylori infection

Helicobacter pylori is a gram-negative, spiral-shaped, flagellated bacterium that colonizes the stomach of half the world's population. Helicobacter pylori infection causes pathologies of varying severity. Standard oral therapy fails in 15-20% since the barriers of the oral route decrease the bioavailability of antibiotics and the intrinsic factors of bacteria increase the rates of resistance. Nanoparticles and microparticles are promising strategies for drug delivery into the gastric mucosa and targeting H. pylori. The variety of building blocks creates systems with distinct colloidal, surface, and biological properties. These features improve drug-pathogen interactions, eliminate drug depletion and overuse, and enable the association of multiple actives combating H. pylori on several fronts. Nanoparticles and microparticles are successfully used to overcome the barriers of the oral route, physicochemical inconveniences, and lack of selectivity of current therapy. They have proven efficient in employing promising anti-H. pylori compounds whose limitation is oral route instability, such as some antibiotics and natural products. However, the current challenge is the applicability of these strategies in clinical practice. For this reason, strategies employing a rational design are necessary, including in the development of nano- and microsystems for the oral route.

Helicobacter pylori Eradication Rate Using Stool Antigen Test in Vietnamese Children: A Prospective Multicenter Study

Objectives

This study assessed the diagnostic value of a monoclonal immunoassay stool antigen test (HpSA) for Helicobacter pylori (H. pylori) infection and the eradication outcomes.

Methods

Children undergoing digestive endoscopy at 2 Children's Hospitals in Ho Chi Minh City were recruited. Treatment was offered to H. pylori-infected children. Stool samples were collected on the same day as the endoscopy procedure and after 6 weeks post-treatment for HpSA. Diagnostic value and optimal cutoff of HpSA were assessed using biopsy-based tests as the gold standard. Eradication was defined as a negative HpSA post-treatment. Ethical approval was obtained, and informed consent was signed by the participants.

Results

In total, 394 patients participated in the study. The most common symptoms were epigastric pain (74.6%) and vomiting (37.3%). H. pylori status was positive in 78% of patients (306/394), doubtful in 10.1%, and negative in 12.2%. HpSA was positive in 73.2% (142/194). Excluding doubtful infections, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of HpSA were 87.4%, 95.2%, 99.2%, 51.3%, and 88.4%, respectively. The optimal cutoff value of 0.148 provided similar accuracy to the recommended cutoff. The eradication rate was 56.1% in per-protocol analysis and 27.9% in intention-to-treat analysis. Treatment success was higher in boys, but lower among malnourished children and those infected with cagA+ strains.

Conclusions

The HpSA is reliable for identifying H. pylori infection in epidemiological studies and assessing eradication outcomes. The low eradication rate highlights the need for an appropriate intervention strategy in Vietnamese children.

Antibiotic resistance, heteroresistance, and eradication success of Helicobacter pylori infection in children

BACKGROUND

Antibiotic resistance is a well-known factor of Helicobacter pylori eradication failure. Heteroresistance indicates the coexistence of resistant and susceptible strains and might lead to underestimating antimicrobial resistance. This study aims to evaluate the susceptibility profile, the frequency of heteroresistance of H. pylori strains, and their effect on eradication success in a pediatric population.

MATERIALS AND METHODS

Children aged 2-17 years who underwent an upper gastrointestinal endoscopy from 2011 to 2019 with positive H. pylori status were included. Susceptibility was measured by disk diffusion and E-test. The difference in susceptibility profiles between isolates from the antrum and the corpus was used to detect heteroresistance. For those who received eradication treatment, we evaluated eradication rate and factors affecting treatment success.

RESULTS

Inclusion criteria were met by 565 children. Strains susceptible to all antibiotics were detected in 64.2%. Primary resistance rates for clarithromycin (CLA), metronidazole (MET), levofloxacin (LEV), tetracyclin (TET), and amoxicillin (AMO) were 11%, 22.9%, 6.9%, 0.4%, and 0% and secondary resistance rates were 20.4%, 29.4%, 9.3%, 0%, and 0%. Heteroresistance was present in untreated children in 2%, 7.1%, 0.7%, 0.7%, and 0% for CLA, MET, LEV, TET, and AMO. First-line eradication rates were 78.5% in intention-to-treat (ITT), 88.3% in full-analysis-set (FAS), and 94.1% in per-protocol (PP). Factors affecting eradication success were the duration of treatment when the triple-tailored treatment was used, the number of daily doses of amoxicillin administered, and the patient's adherence to treatment.

CONCLUSIONS

This study shows the presence of relatively low primary resistance rates for H. pylori isolates but demonstrates the presence of heteroresistance in our population. Routine biopsies from the antrum and corpus must be considered for susceptibility testing to allow tailored treatments and increase eradication rates. Treatment success is affected by treatment choice, correct dosing of medications, and adherence. All these factors should be considered when evaluating the efficacy of an eradication regimen.

Helicobacter pylori Infections in Children

In the context of epidemiology, host response, disease presentation, diagnosis, and treatment management, the manifestation of Helicobacter pylori (H. pylori) infection diverges between children and adults. H. pylori infection stands out as one of the most prevalent bacterial infections globally, and its prevalence in both children and adults is decreasing in many developing countries but some still struggle with a high prevalence of pediatric H. pylori infection and its consequences. The majority of infected children are asymptomatic and pediatric studies do not support the involvement of H. pylori in functional disorders such as recurrent abdominal pain. The pathophysiology of H. pylori infection relies on complex bacterial virulence mechanisms and their interaction with the host immune system and environmental factors. This interaction gives rise to diverse gastritis phenotypes, which subsequently influence the potential development of various gastroduodenal pathologies. In clinical settings, the diagnosis of this infection in childhood requires an upper gastrointestinal endoscopic exam with mucosal biopsy samples for histology and culture, or Polymerase Chain Reaction (PCR) at the very least. When warranted, eradication treatment should be given when good compliance is expected, and there should be systematic use of a treatment adapted to the antimicrobial susceptibility profile. To combat the burgeoning threat of multidrug resistance, vigilant surveillance of resistance patterns and strategic antibiotic management are paramount.

Therapeutic eradication choices in Helicobacter pylori infection in children

Current recommendations on Helicobacter pylori (H. pylori) eradication in children differ from adults. In H. pylori-infected adults, the eradication is always recommended because of the risk to develop gastrointestinal and non-gastrointestinal associated diseases. Instead, before treating infected children, we should consider all the possible causes and not merely focus on H. pylori infection. Indeed, pediatric international guidelines do not recommend the test and treat strategy in children. Therefore, gastroscopy with antimicrobial susceptibility testing by culture on gastric biopsies should be performed before starting the eradication therapy in children to better evaluate all the possible causes of the symptomatology and to increase the eradication rate. Whether antibiotic susceptibility testing is not available, gastroscopy is anyway recommended to better set any possible cause of symptoms and not simply focus on the presence of H. pylori. In children the lower antibiotics availability compared to adults forces to treat based on antimicrobial susceptibility testing to minimize the unsuccessful rates. The main antibiotics used in children are amoxicillin, clarithromycin, and metronidazole in various combinations. In empirical treatment, triple therapy for 14 days based either on local antimicrobial susceptibility or on personal antibiotic history is generally recommended. Triple therapy with high dose of amoxicillin is a valid alternative choice, either in double resistance or in second-line treatment. Moving from therapeutic regimens used in adults, we could also select quadruple therapy with or without bismuth salts. However, all the treatment regimens often entail unpleasant side effects and lower compliance in children. In this review, the alternative and not yet commonly used therapeutic choices in children were also analyzed.

In vitro evaluation of the antibacterial effect of colloidal bismuth subcitrate on Porphyromonas gingivalis and its biofilm

OBJECTIVE

To investigate the antibacterial and anti-biofilm effects of colloidal bismuth subcitrate (CBS) on Porphyromonas gingivalis (P. gingivalis) in its planktonic and biofilm forms and also compare it with that of 0.2% chlorhexidine (CHX).

DESIGN

The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of CBS were determined by the microdilution method; the bacteriostatic rate of CBS was determined by the MTT assay; the effect of CBS on the membrane integrity of P. gingivalis was investigated by the flow cytometric methods. The effects of CBS on the biomass and bacterial activity of biofilm were investigated. Confocal laser scanning microscopy (CLSM) and scanning electron microscopy (SEM) were used to investigate the activity and structure of biofilms.

RESULTS

The MIC and MBC values were 18.75 µg/mL and 37.5 µg/mL. CBS could damage the cell membrane of P. gingivalis. CBS effectively inhibited biofilm formation and promoted dissociation at higher concentrations of 37.5 µg/mL and 75 µg/mL, respectively. The results also indicated an altered biofilm structure and reduced biofilm thickness and bacterial aggregation.

CONCLUSIONS

CBS affected the metabolic and physiological processes of P. gingivalis, inhibited the formation of biofilm, and disrupted the mature biofilm.