Rescue therapy with rifabutin regimen for refractory Helicobacter pylori infection with dual drug-resistant strains

Novel DNA gyrase mutations in levofloxacin-resistant Helicobacter pylori isolates from southern Vietnam

BACKGROUND

The escalating antibiotic resistance in Helicobacter pylori (H. pylori) has become a significant concern in the management of infections. This study aimed to investigate the mutations associated with levofloxacin resistance in H. pylori isolated from southern Vietnam.

METHODS

Levofloxacin-resistant H. pylori strains were isolated from peptic ulcer patients and DNA sequencing of DNA gyrase (gyrA and gyrB) genes was performed.

RESULTS

We found that 97 % of resistant isolates bearing at least one mutation in GyrA and 32.3 % had a simultaneous mutation in GyrB. Additionally, we identified three previously known mutations, G85C (1.5 %), N87 (34.3 %), and D91 (14.9 %), within the quinolone-resistance-determining region (QRDR) region of GyrA, which confer resistance through natural transformation and were the most prevalent in our study. Notably, we demonstrated a mutation (A88V MIC 4 μg/mL) in GyrA and four novel mutations (E422R MIC 16 μg/mL, A426G MIC 32 μg/mL, S429E MIC 4 μg/mL, and P443A MIC 4 μg/mL) in GyrB, belonging to the QRDR. Additionally, several mutations outside the QRDR were observed, including R190K (16.4 %), P219A/G (13.4 %), L45F (9 %), P220E (6 %), Y28I (4.5 %), A27L (3 %) in GyrA, and S457A (7.5 %), A382F (5.9 %), L389F (4.5 %), D412R (1.5 %), L460P (1.5 %), I482V (1.5 %), and L518E (1.5 %) that have not been documented in any previous studies and were not functionally validated.

CONCLUSION

These results highlight the high genetic diversity and prevalence of levofloxacin-resistant H. pylori strains in southern Vietnam and provide valuable insights into levofloxacin resistance mechanisms for future diagnostic and treatment advancements.

Efficacy of Rifabutin-Based Helicobacter pylori Eradication Regimen in Korea With High Prevalence of Tuberculosis Infection

BACKGROUND

As the antibiotic resistance and treatment failure rates of Helicobacter pylori are rising, the need for rescue therapy with rifabutin for H. pylori eradication (HPE) is also increasing. Therefore, in this study, we investigated the efficacy, resistance status, and adverse events in patients receiving rifabutin-based HPE.

MATERIALS AND METHODS

Between January 2020 and December 2022, 3006 patients underwent esophagogastroduodenoscopy (EGD) with H. pylori culture tests. Of these, culture results were successfully obtained from 1792 patients, who were subsequently enrolled in our study. The medical records of these patients were retrospectively reviewed, and their clinical features and outcomes assessed.

RESULTS

Among the 1792 patients, 14 (0.8%) were rifabutin-resistant. A total of 665 (37.1%) patients had multidrug-resistant (MDR) H. pylori infections. Patients with rifabutin-resistant H. pylori infections had a significantly higher rate of tuberculosis treatment history (2.8% vs. 28.6%, p < 0.001) and MDR H. pylori infections (49.6% vs. 85.7%, p < 0.001) than those in the rifabutin-susceptible H. pylori group. Among the 45 patients who received the rifabutin-based HPE regimen, 44 (97.8%) had MDR H. pylori infection, and 35 (77.8%) underwent rifabutin-based HPE as a third-line treatment or beyond. A total of 31 (68.9%) showed successful eradication. Nineteen (42.2%) patients experienced at least one symptom of adverse events; however, the severity of side effects was mild, and no patient discontinued treatment because of this.

CONCLUSIONS

The rifabutin-based HPE regimen could be an effective and safe treatment method. It is particularly considered a viable therapeutic option for patients who require HPE but have previously failed to respond to multiple HPEs.

Molecular characterization of rifabutin-resistance in refractory Helicobacter pylori infection in Taiwan

OBJECTIVES

To explore the molecular characteristics of rpoB, encoding β-subunit of DNA-directed RNA polymerase, and unravel the link to rifabutin-resistance in patients with refractory Helicobacter pylori infection.

METHODS

From January 2018-March 2021, a total of 1590 patients were screened for eligibility to participate in the study. Patients with refractory H. pylori infection were confirmed by using the (13C)-urea breath assay. All enrolled patients underwent esophagogastroduodenoscopy, and biopsies were taken for H. pylori culture and antibacterial susceptibility testing. Sequence analysis of rpoB was conducted for all rifabutin-resistant isolates.

RESULTS

In total, 70 patients were diagnosed with refractory H. pylori infection, and 39 isolates were successfully cultured. Amongst, 10 isolates were identified as rifabutin-resistance and nine isolates exhibited at least one amino acid substitution in RpoB. Isolates with a minimal inhibitory concentration >32 mg/l displayed a higher number of mutational changes in RpoB than the others. Additionally, more amino acid substitutions in RpoB correlated with developing a higher minimal inhibitory concentration for H. pylori rifabutin-resistance.

CONCLUSION

Our findings highlight the relationship between rifabutin-resistance in refractory H. pylori infection and specific mutations in RpoB, which will aid the clinical selection of appropriate antibacterial agents with better therapeutic effects.

Multiple amino acid substitutions in penicillin-binding protein-1A confer amoxicillin resistance in refractory Helicobacter pylori infection

BACKGROUND

Amoxicillin resistance in Helicobacter pylori is mainly associated with mutations in penicillin-binding protein-1A (PBP-1A). However, the specific amino acid substitutions in PBP-1A that confer amoxicillin resistance in H. pylori remain to be investigated.

OBJECTIVE

This study aimed to investigate the molecular mechanism underlying amoxicillin resistance in patients with refractory H. pylori infection.

METHODS

Esophagogastroduodenoscopy (EGD) was performed in patients with persistent H. pylori infection after at least two courses of H. pylori eradication therapy between January-2018 to March-2021. Refractory H. pylori was cultured from the gastric biopsy specimens. Antibiotic susceptibility testing was conducted to determine the minimum inhibitory concentrations (MICs). Sequence analysis of pbp-1A was performed for amoxicillin-resistant strains.

RESULTS

Thirty-nine successfully cultured isolates were classified as refractory H. pylori isolates, and seventeen isolates were resistant to amoxicillin (MIC > 0.125 mg/L). Sequence analysis of resistant strains showed multiple mutations in the C-terminal region of PBP-1A that conferred amoxicillin resistance in H. pylori. However, the number of PBP-1A mutations did not correlate with the high MICs of amoxicillin-resistant isolates. Notably, some amino acid substitutions were identified in all Taiwanese isolates with history of eradication failure but not in published amoxicillin-susceptible strains, suggesting that the mutations may play a role in conferring antibiotic resistance to these strains.

CONCLUSIONS

Our results show that amoxicillin resistance in refractory H. pylori is highly correlated with numerous PBP-1A mutations that are strain specific. Continuous improvements in diagnostic tools, particularly molecular analysis approaches, can help to optimize current antimicrobial regimens.

Third-line and rescue therapy for refractory Helicobacter pylori infection: A systematic review

BACKGROUND

Due to increasing resistance rates of Helicobacter pylori (H. pylori) to different antibiotics, failures in eradication therapies are becoming more frequent. Even though eradication criteria and treatment algorithms for first-line and second-line therapy against H. pylori infection are well-established, there is no clear recommendation for third-line and rescue therapy in refractory H. pylori infection.

AIM

To perform a systematic review evaluating the efficacy and safety of rescue therapies against refractory H. pylori infection.

METHODS

A systematic search of available rescue treatments for refractory H. pylori infection was conducted on the National Library of Medicine’s PubMed search platform based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized or non-randomized clinical trials and observational studies evaluating the effectiveness of H. pylori infection rescue therapies were included.

RESULTS

Twenty-eight studies were included in the analysis of mean eradication rates as rescue therapy, and 21 of these were selected for analysis of mean eradication rate as third-line treatment. For rifabutin-, sitafloxacin-, levofloxacin-, or metronidazole-based triple-therapy as third-line treatment, mean eradication rates of 81.6% and 84.4%, 79.4% and 81.5%, 55.7% and 60.6%, and 62.0% and 63.0% were found in intention-to-treat (ITT) and per-protocol (PP) analysis, respectively. For third-line quadruple therapy, mean eradication rates of 69.2% and 72.1% were found for bismuth quadruple therapy (BQT), 88.9% and 90.9% for bismuth quadruple therapy, three-in-one, Pylera^® (BQT-Pylera), and 61.3% and 64.2% for non-BQT) in ITT and PP analysis, respectively. For rifabutin-, sitafloxacin-, levofloxacin-, or metronidazole-based triple therapy as rescue therapy, mean eradication rates of 75.4% and 78.8%, 79.4 and 81.5%, 55.7% and 60.6%, and 62.0% and 63.0% were found in ITT and PP analysis, respectively. For quadruple therapy as rescue treatment, mean eradication rates of 76.7% and 79.2% for BQT, 84.9% and 87.8% for BQT-Pylera, and 61.3% and 64.2% for non-BQT were found in ITT and PP analysis, respectively. For susceptibility-guided therapy, mean eradication rates as third-line and rescue treatment were 75.0% in ITT and 79.2% in PP analysis.

CONCLUSION

We recommend sitafloxacin-based triple therapy containing vonoprazan in regions with low macrolide resistance profile. In regions with known resistance to macrolides or unavailability of bismuth, rifabutin-based triple therapy is recommended.

Helicobacter pylori Standard Triple Therapy Outcomes in Iranian Population: A Retrospective Population-based Study in Mashhad, Northeast of Iran

Background: Helicobacter pylori infection is one of the most prevalent infections in many areas of the world, which is treated with different combinations of medications. Objectives: This study aimed to investigate the response rate and outcomes of H. pylori-infected Iranian patients treated with triple therapy. Methods: The current study examined the records of patients with dyspepsia referred to Imam Reza hospital's gastroenterology clinic in Mashhad, Iran, diagnosed with H. pylori from 2017 to 2019. The patients received the triple therapy for H. pylori and were divided into responsive and non-responsive groups. Results: Out of the 750 patients, 477 were included in the study. The response rate to H. pylori standard triple therapy was 79% after 14 days of treatment. Patients aged 30 - 39 years had the highest rate of treatment response. There was no significant relationship between the response rate to treatment and smoking (P = 0.74), alcohol consumption (P = 0.91), opium addiction (P = 0.89), history of aspirin (P = 0.46) or nonsteroidal anti-inflammatory drugs (NSAIDs) use (P = 0.66), diabetes (P = 0.18), renal failure (P = 0.054), and family history of GI malignancies (P = 0.51). Furthermore, patients with gastric ulcer (P = 0.43), duodenal ulcer (P = 0.66), and gastric precancerous lesions (P = 0.93) showed no significant difference in response to treatment. Conclusions: The H. pylori triple therapy regimen can be an effective medication strategy for H. pylori infection in the Iranian population.

Treatment of refractory Helicobacter pylori infection: A new challenge for clinicians

Patients who have failed two or more attempts to eradicate Helicobacter pylori are commonly referred to as refractory. Although the incidence of refractory Helicobacter pylori infection is only 10–20%, with the increasing rate of antibiotic resistance in various regions, the treatment of refractory Helicobacter pylori infection has gradually become a difficult problem faced by clinicians. When choosing a rescue therapy, the physician must consider numerous factors. A longer treatment duration, higher doses of proton pump inhibitors (PPIs), or the use of potassium-competitive acid blocker (P-CAB) may increase the efficacy of triple therapy or bismuth quadruple therapy. Rescue treatment based on bismuth quadruple therapy usually achieves better results. At the same time, treatment based on drug susceptibility tests or genotypic resistance is recommended where available. Of course, appropriate empiric treatment can also be selected according to local drug resistance, a patient’s previous medication history and compliance. It is the best choice if it can improve the success rate of the first treatment and reduce the occurrence of refractory Helicobacter pylori infection. This review aims to summarize the articles related to refractory Helicobacter pylori in recent years and to explore a better remedial treatment plan for clinicians.

Modifications, biological origin and antibacterial activity of naphthalenoid ansamycins

Covering: 2011 to 2021Structural division of natural naphthalenoid ansamycins, regarding the type of the core and length of the ansa chain, and their biosynthetic pathways in microorganisms are discussed. The great biosynthetic plasticity of natural naphthalenoid ansamycins is reflected in their structural variety due to the alterations within ansa bridge or naphthalenoid core portions. A comparison between the biological potency of natural and semisynthetic naphthalenoid ansamycins was performed and discussed in relation to the molecular targets in cells. The antibacterial potency of naphthalenoid ansamycins seems to be dependent on the ansa chain length and conformational flexibility - the higher flexibility of the ansa chain the better biological outcome is noted.

Multidrug resistance: The clinical dilemma of refractory Helicobacter pylori infection

This study investigated the antimicrobial resistance of isolates from patients with refractory Helicobacter pylori. The resistance rate was 34.1% for amoxicillin, 92.7% for clarithromycin, 65.9% for metronidazole, 85.4% for levofloxacin, and 29.3% for rifabutin. Dual resistance to both clarithromycin and levofloxacin was found in 73.2%. The antimicrobial resistance rate of refractory H. pylori was extremely high, which had become a major consideration in therapeutic challenge.

Evaluating treatments with rifabutin and amoxicillin for eradication of Helicobacter pylori infection in adults: a systematic review

INTRODUCTION

Helicobacter pylori causes dyspepsia, peptic ulcer, and gastric malignancies. Treatments for Helicobacter pylori are mostly empirical depending on regional antibiotic resistances and the patient's history and less frequently susceptibility guided. Helicobacter pylori has a low resistance to rifabutin and has been proposed as an alternative for third-line treatment and beyond but recently has also gained attention for use as first- and second-line treatment.

AREAS COVERED

In this review, the authors systematically searched medical databases in order to present the current eradication rates for any treatment based on the two antibiotics, rifabutin and amoxicillin with a potent acid inhibitor. They also assessed the safety and tolerance of all the relative regimens.

EXPERT OPINION

Treatment with a rifabutin- and amoxicillin-containing regimen is a valuable option when treating difficult to eradicate Helicobacter pylori infections. Its efficacy is overall 71.4%, and it is not influenced by previous antibiotics, gender, smoking habits, and age. Its results were better when used as a first- or second-line treatment. In third-line therapy and beyond, eradication rates are lower. Adverse effects of all rifabutin regimens occurred in 23% of patients and were mostly mild with bone marrow suppression being very low and reversible.

Treatment Approach of Refractory Helicobacter pylori Infection: A Comprehensive Review

H. pylori is the most common infection in the world and is associated with gastrointestinal and extra-gastrointestinal manifestations, including peptic ulcer disease, gastrointestinal bleeding, and lymphoproliferative disorders. Despite being discovered less than half a century ago, antibiotic resistance, exacerbated by medication non-adherence and inefficacy of proton pump inhibitors, has grown substantially, explaining the rising incidence of refractory H. pylori infection. In this review, we discuss risk factors, treatment options, surveillance and follow-up, as well as emerging therapies for refractory H. pylori.

Rifabutin for the Treatment of Helicobacter Pylori Infection: A Review

Nowadays, apart from having to know first-line Helicobacter pylori eradication regimens well, we must also be prepared to face treatment failures. The aim of this review is to summarize the role of rifabutin in the management of H. pylori infection. Bibliographical searches were performed in PubMed. Data on resistance and efficacy of rifabutin-containing regimens on H. pylori eradication were meta-analyzed. Mean H. pylori rifabutin resistance rate (39 studies, including 9721 patients) was 0.13%; when studies only including patients naïve to H. pylori eradication treatment were considered, this figure was even lower (0.07%). Mean H. pylori eradication rate (by intention-to-treat) with rifabutin-containing regimens (3052 patients) was 73%. Respective cure rates for second-, third-, fourth- and fifth-line therapies, were 79%, 69%, 69% and 72%. Most studies administered rifabutin 300 mg/day, which seemed to be more effective than 150 mg/day. The ideal length of treatment remains unclear, but 10–12-day regimens are generally recommended. Adverse events to rifabutin treatment in H. pylori studies were relatively infrequent (15%), and severe adverse events were exceptional (myelotoxicity was the most significant, although always reversible). In summary, rifabutin-containing therapy represents an encouraging strategy generally restricted, at present, to patients where previous (usually multiple) eradication regimens have failed.

An update on current and advancing pharmacotherapy options for the treatment of H. pylori infection

Introduction: Eradication of Helicobacter pylori (H. pylori) becomes more challenging due to increasing antimicrobial resistance. Consequently, the performance of clarithromycin-containing triple therapies is now declining to unacceptable levels and should be abandoned unless a prior susceptibility test precludes clarithromycin resistance.Areas covered: This review summarizes updated evidence concerning new and advancing pharmacotherapy options for H. pylori eradication.Expert opinion: Due to the declining efficacy of legacy triple therapies, most guidelines recommend bismuth quadruple therapy as the best initial empiric treatment. Concomitant, sequential and hybrid therapies are remarkable bismuth-free quadruple options, provided that dual clarithromycin-metronidazole resistance is low. Levofloxacin-, rifabutin-, furazolidone- and sitafloxacin-containing regimens remain useful, particularly as salvage options. To eradicate H. pylori in line with the rules of antibiotic stewardship, susceptibility-guided treatment appears as the ideal approach. However, the feasibility and cost-effectiveness of universal pre-treatment susceptibility testing warrants further evaluation. Molecular testing methods promise convenient characterization of H. pylori antibiotic susceptibility. High-dose dual therapy (proton-pump-inhibitor plus amoxicillin) and vonoprazan, a more potent acid inhibitor that likely enhances the activity of amoxicillin, are promising alternatives that could decrease misuse of antibiotics. Addition of certain probiotics could somewhat increase the performance of H. pylori eradication regimens, while improving tolerability.