Update on the first-line treatment of Helicobacter pylori infection in areas with high and low clarithromycin resistances

Prevalence, associated factors, and clinical outcomes of Helicobacter pylori infection in pediatric populations in a war-torn urban environment in Eastern Democratic Republic of Congo: a mixed methods study

BACKGROUND

Helicobacter pylori (H. pylori) infection remains a significant public health concern in developing countries, especially among pediatric populations where data are limited. In war-torn regions like the Eastern Democratic Republic of Congo, the impact of H. pylori infection on children's health may be exacerbated due to disrupted healthcare systems and limited resources.

METHODS

This mixed-methods study, incorporating both cross-sectional and prospective cohort designs, was conducted at Samaritan Doctor's Pediatric Centre between January 2020 and December 2022. The study enrolled 323 children aged 0 to 15 years presenting with gastrointestinal symptoms. Sociodemographic and clinical characteristics were assessed via questionnaire, and H. pylori stool antigen rapid tests were performed. Multivariate regression analyses were conducted. Participants were followed up and outcomes recorded after 30 days.

RESULTS

Of the 323 participants, 119 (36.80%) tested positive for H. pylori infection. Independent factors associated with H. pylori infection included age between 37 and 59 months (aOR: 9.76, 95% CI: 2.62-36.40, p = 0.001), caretaker's occupation (aOR: 2.58, 95% CI: 1.19-5.54, p = 0.016), presence of pets at home (aOR: 0.371, 95% CI: 0.18-0.74, p = 0.005), drinking unsafe water (aOR: 0.13, 95% CI: 0.04-0.42, p = 0.001), anemia (aOR: 4.80, 95% CI: 1.12-20.53, p = 0.034), and presence of red blood cells in stool (aOR: 30.84, 95% CI: 13.97-68.10, p < 0.0001). Thirty days post-initial treatment with first-line medications (omeprazole, clarithromycin, and amoxicillin), 19.30% of patients remained positive for H. pylori.

CONCLUSION

Children with occult blood in stool and microcytic anemia should be tested for H. pylori using stool antigen tests. Treatment with clarithromycin should be guided by local antibiotic resistance data. Hygiene education, including safe water practices and managing pet contact, is crucial due to their association with H. pylori infection.

Rapid diagnosis and precision treatment of Helicobacter pylori infection in clinical settings

Helicobacter pylori is a gram-negative bacterium that colonizes the stomach of approximately half of the worldwide population, with higher prevalence in densely populated areas like Asia, the Caribbean, Latin America, and Africa. H. pylori infections range from asymptomatic cases to potentially fatal diseases, including peptic ulcers, chronic gastritis, and stomach adenocarcinoma. The management of these conditions has become more difficult due to the rising prevalence of drug-resistant H. pylori infections, which ultimately lead to gastric cancer and mucosa-associated lymphoid tissue (MALT) lymphoma. In 1994, the International Agency for Research on Cancer (IARC) categorized H. pylori as a Group I carcinogen, contributing to approximately 780,000 cancer cases annually. Antibiotic resistance against drugs used to treat H. pylori infections ranges between 15% and 50% worldwide, with Asian countries having exceptionally high rates. This review systematically examines the impacts of H. pylori infection, the increasing prevalence of antibiotic resistance, and the urgent need for accurate diagnosis and precision treatment. The present status of precision treatment strategies and prospective approaches for eradicating infections caused by antibiotic-resistant H. pylori will also be evaluated.

In Silico Identification of Potential Clovibactin-like Antibiotics Binding to Unique Cell Wall Precursors in Diverse Gram-Positive Bacterial Strains

The rise in multidrug-resistant bacteria highlights the critical need for novel antibiotics. This study explores clovibactin-like compounds as potential therapeutic agents targeting lipid II, a crucial component in bacterial cell wall synthesis, using in silico techniques. A total of 2624 clovibactin analogs were sourced from the PubChem database and screened using ProTox 3.0 software based on their ADME-Tox properties, prioritizing candidates with favorable pharmacokinetic profiles and minimal toxicity. Molecular docking protocols were then employed to assess the binding interactions of the selected compounds with lipid II. Our analysis identified Compound 22 as a particularly promising candidate, exhibiting strong binding affinity, stable complex formation, and high selectivity for the target. Binding energy analysis, conducted via molecular dynamics simulations, revealed a highly negative value of -25.50 kcal/mol for Compound 22, surpassing that of clovibactin and underscoring its potential efficacy. In addition, Compound 22 was prioritized due to its exceptional binding affinity to lipid II and its favorable ADME-Tox properties, suggesting a lower likelihood of adverse effects. These characteristics position Compound 22 as a promising candidate for further pharmacological development. While our computational results are encouraging, experimental validation is essential to confirm the efficacy and safety of these compounds. This study not only advances our understanding of clovibactin analogs but also contributes to the ongoing efforts to combat antimicrobial resistance through innovative antibiotic development.

Modern approaches to the eradication of <i>Helicobacter pylori</i>: a spectrum of perspectives

Helicobacter pylori is one of the most widespread infections, affecting approximately 50% of the global population, with the Russian Federation ranking among the regions with a relatively high prevalence. Eradication therapy remains the primary strategy, not only for the treatment and prevention of gastrointestinal diseases but also for reducing the risk of stomach cancer, highlighting the medical and social impact of this infection. A key factor contributing to the reduced effectiveness of eradication therapy is the microorganism’s primary or secondary resistance to antibacterial drugs, a problem recognized worldwide. It is widely acknowledged that national treatment regimens for Helicobacter pylori infection must be adapted based on systematic antimicrobial sensitivity testing to curb the rise of global antibiotic resistance. Despite decades of research and clinical practice, identifying the most effective, safe, and straightforward therapy remains a significant challenge for clinicians. This review provides a comparative analysis of current treatment recommendations for Helicobacter pylori infection, as presented by various national and regional gastroenterological societies, including those relevant in the Russian Federation.

Genomic insights into the antimicrobial resistance and virulence of Helicobacter pylori isolates from gastritis patients in Pereira, Colombia

BACKGROUND

Helicobacter pylori infects the stomach and/or small intestines in more than half of the human population. Infection with H. pylori is the most common cause of chronic gastritis, which can lead to more severe gastroduodenal pathologies such as peptic ulcer, mucosa-associated lymphoid tissue lymphoma, and gastric cancer. H. pylori infection is particularly concerning in Colombia in South America, where > 80% of the population is estimated to be infected with H. pylori and the rate of stomach cancer is one of the highest in the continent.

RESULTS

We compared the antimicrobial susceptibility profiles and short-read genome sequences of five H. pylori isolates obtained from patients diagnosed with gastritis of varying severity (chronic gastritis, antral erosive gastritis, superficial gastritis) in Pereira, Colombia sampled in 2015. Antimicrobial susceptibility tests revealed the isolates to be resistant to at least one of the five antimicrobials tested: four isolates were resistant to metronidazole, two to clarithromycin, two to levofloxacin, and one to rifampin. All isolates were susceptible to tetracycline and amoxicillin. Comparative genome analyses revealed the presence of genes associated with efflux pump, restriction modification systems, phages and insertion sequences, and virulence genes including the cytotoxin genes cagA and vacA. The five genomes represent three novel sequence types. In the context of the Colombian and global populations, the five H. pylori isolates from Pereira were phylogenetically distant to each other but were closely related to other lineages circulating in the country.

CONCLUSIONS

H. pylori from gastritis of different severity varied in their antimicrobial susceptibility profiles and genome content. This knowledge will be useful in implementing appropriate eradication treatment regimens for specific types of gastritis. Understanding the genetic and phenotypic heterogeneity in H. pylori across the geographical landscape is critical in informing health policies for effective disease prevention and management that is most effective at local and country-wide scales. This is especially important in Colombia and other South American countries that are poorly represented in global genomic surveillance studies of bacterial pathogens.

Recent trends in Helicobacter pylori management: harnessing the power of AI and other advanced approaches

Background

Helicobacter pylori (H. pylori) is a bacterial infection that is prevalent and affects more than half of the world's population, causing stomach disorders such as gastritis, peptic ulcer disease, and gastric cancer.

Main body

The diagnosis of H. pylori infection relies on invasive and non-invasive techniques emerging artificial intelligence, and antibiotic therapy is available, but antibiotic resistance is a growing concern. The development of a vaccine is crucial in preventing H. pylori-associated diseases, but it faces challenges due to the bacterium's variability and immune escape mechanisms. Despite the challenges, ongoing research into H. pylori's virulence factors and immune escape mechanisms, as well as the development of potential vaccine targets, provides hope for more effective management and prevention of H. pylori-associated diseases. Recent research on H. pylori's immune escape mechanisms and novel immune checkpoint inhibitors could also lead to biomarkers for early cancer detection. Therefore, experts have suggested a combination of traditional and herbal medicine with artificial intelligence to potentially eradicate H. pylori.

Short conclusion

H. pylori infection remains a significant global health problem, but ongoing research into its properties and advanced technologies in addition to the combination of traditional and herbal medicine with artificial intelligence may also lead to the eradication of H. pylori-associated diseases.

Graphical abstract

Targeted delivery of a short antimicrobial peptide (CM11) against Helicobacter pylori gastric infection using concanavalin A-coated chitosan nanoparticles

Helicobacter pylori is the cause of most cases of stomach ulcers and also causes some digestive cancers. The emergence and spread of antibiotic-resistant strains of H. pylori is one of the most important challenges in the treatment of its infections. The present study aims to develop a concanavalin A (ConA) coated chitosan (CS) nanocarrier-based drug delivery for the targeted release of peptides to the site of H. pylori infection. Accordingly, chitosan was used as an encapsulating agent for CM11 peptide delivery by applying ionotropic gelation method. Con-A was used for coating CS nanoparticles to target H. pylori. The CS NPs and ConA-CS NPs were characterized by FTIR, dynamic light scattering (DLS), and scanning electron microscopy (SEM). The MIC of CM11-loaded ConA-CS NPs against H. pylori SS1 strain was analyzed in vitro. In order to evaluate the treatment efficiency in vivo, a gastric infection model of H. pylori SS1 strain was established in mice and histopathological studies and IL-1β cytokine assay were performed. Based on the results, the size frequency for CS NPs and ConA-CS NPs was about 200 and 350 nm, respectively. The prepared CM11-loaded ConA-CS NPs exhibited antibacterial activity against H. pylori SS1 strain with a concentration of 32 µg/ml. The highest healing process was observed in synthesized CM11-loaded ConA-CS NPs treatments and a significant decrease in IL-1β was observed. Our findings highlight the potential of chitosan nanoparticles as a drug delivery vehicle in the treatment of gastric infection model of H. pylori SS1 strain.

Efficacy and safety of vonoprazan-amoxicillin dual therapy for Helicobacter pylori first-line treatment: a single-center, randomized, controlled trial

Background

With the increase in antibiotic resistance, the success rate of Helicobacter pylori (H. pylori) eradication therapy has declined in recent years. Vonoprazan-amoxicillin (VA) dual therapy has been reported to be a promising regimen.

Objectives

To compare the efficacy and safety of VA dual therapy and bismuth quadruple therapy containing amoxicillin and clarithromycin for H. pylori first-line eradication, and to further analyze the effects of clarithromycin resistance on eradication rate.

Design

This study was a single-center, open-label, randomized controlled trial.

Methods

Treatment-naïve H. pylori-infected patients were randomly allocated 1:1 to the VA group (vonoprazan 20 mg twice daily and amoxicillin 750 mg four times daily, for 14 days) or the RBAC group (rabeprazole 10 mg, bismuth potassium citrate 220 mg, amoxicillin 1000 mg and clarithromycin 500 mg twice daily, for 14 days). H. pylori clarithromycin resistance and CYP2C19 gene polymorphisms were detected with real-time polymerase chain reaction (PCR) technique. The eradication rates and adverse events were analyzed.

Results

A total of 151 patients were enrolled. The intention-to-treat (ITT), modified intention-to-treat (mITT), and per-protocol (PP) eradication rates and their 95% confidence intervals (95% CIs) were 94.6% (86.0-98.3%), 98.6% (91.3-99.9%), and 98.5% (90.9-99.9%) for VA group and 87.0% (77.0-93.3%), 91.8% (82.3-96.6%), and 93% (83.7-97.4%) for RBAC group. The eradication rate of the VA group was noninferior to the RBAC group in ITT, mITT, and PP analyses (p < 0.0001). In patients infected with strains of clarithromycin resistance point mutation, the eradication rate of the RBAC group decreased to lower than 90%, but the difference from the VA group did not achieve statistical significance (ITT eradication rate: 81.5% in the RBAC group and 96.2% in the VA group, p = 0.192). The incidence of adverse events in the VA group was 39.2%, which was significantly lower than that in the RBAC group (79.2%, p = 0.000).

Conclusion

The efficacy of VA dual therapy is noninferior to RBAC in H. pylori first-line eradication, with fewer adverse reactions.

Registration

This study was registered at the Chinese Clinical Trial Registry (ChiCTR2100052550) on 30 October 2021.

The Efficacy and Safety of 14-day Rabeprazole Plus Amoxicillin High Dose Dual Therapy by Comparing to 14-day Rabeprazole-Containing Hybrid Therapy for the Naïve Helicobacter pylori Infection in Taiwan: A Randomized Controlled Trial

INTRODUCTION

High-dose dual therapy (HDDT) can attain acceptable eradication rates provided that the optimal doses, timing and treatment duration are applied. The existing evidence still shows inconsistent reports (< 90%) on HDDT therapy except in some Asian countries. We aimed to assess and compare the efficacy of 14-day HDDT by comparing it to 14-day rabeprazole-containing hybrid therapy (HT) and to investigate the host and bacterial factors predicting the treatment outcomes of eradication therapies.

METHODS

In this open-label, randomized controlled trial, we recruited 243 naïve Helicobacter pylori-infected patients from September 1, 2018, to November 30, 2021. They were randomly allocated (1:1) to the HDDT group (rabeprazole 20 mg and amoxicillin 750 mg q.i.d for 14 days, n = 122) and the HT group (rabeprazole 20 mg and amoxicillin 1 g b.i.d. for 7 days, followed by rabeprazole 20 mg, amoxicillin 1 g, clarithromycin 500 mg and metronidazole 500 mg b.i.d. for 7 days, n = 121). Twelve patients were absent during follow-up in the HDDT group and 4 in the HT group, resulting in 110 for the HDDT group and 117 for HT group in the per protocol (PP) study. The outcome was determined by urea breath tests 8 weeks later.

RESULTS

The eradication rates for the HDDT and HT groups were 77.0% (95% confidence interval [CI]: 68.5% to 84.1%) and 94.2% (95% CI: 88.4% to 97.6%) (P < 0.001) in intention-to-treat analysis; 85.5% (95% CI: 77.5% to 91.5%) and 97.4% [95% CI: 92.6% to 99.5%] (P = 0.001) in per protocol analysis. The adverse event rates were 7.3% in the HDDT group and 14.5% in the HT group (P = 0.081). The habit of coffee drinking was the dependent factor for eradication failure in the HDDT group (88.2% vs. 68.8%, P = 0.040), but had no influence in the HT group (97.9% versus 95.0%, P = 0.449) in the univariate analysis.

CONCLUSION

This study demonstrated that 14-day rabeprazole-containing HDDT did not achieve > 90% eradication rates for first-line H. pylori eradication as 14-day rabeprazole-containing HT did. HDDT is a potentially beneficial combination, which involves only two drugs with mild adverse effects; more precise studies are urged to find answers regarding these failures. This clinical trial was registered retrospectively on 28 November, 2021, as ClinicalTrials.gov identifier: NCT05152004.