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Tabesh E, Yadmehr F, Feizi A, Khorvash F, Sindarreh S, Hakamifard A. Sequential therapy versus quadruple therapy for Helicobacter pylori eradication: A prospective double-blinded randomized controlled trial. Health Sci Rep 2024; 7:e1842. [PMID: 38274136 PMCID: PMC10808940 DOI: 10.1002/hsr2.1842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 12/15/2023] [Accepted: 01/08/2024] [Indexed: 01/27/2024] Open
Abstract
Backgrounds and Aims This controlled randomized clinical trial was designed to compare effectiveness, side effects, and severity of symptoms before and after therapy between quadruple (QT) and sequential regimens (SQ) for Helicobacter Pylori (H. pylori). Methods Patients were randomly allocated into two groups. Group A received a 14-day QT including pantoprazole 40 mg q12 h, bismuth subcitrate 240 mg q12 h, clarithromycin 500 mg q12 h, and amoxicillin 1000 mg q12 h and group B received ST including pantoprazole 40 mg q12 h and amoxicillin 1000 mg q12 h for the initial 5 days followed by pantoprazole 40 mg q12 h, clarithromycin 500 mg q12 h and tinidazole 500 mg q12 h for the next 5 days. Adverse drug reactions and patients' compliance were assessed after finishing the treatment course and also 4 weeks after. All patients were naive, therefore ST and QT were first-line therapies. To evaluate severity of symptoms we used Short-Form Leeds Dyspepsia Questionnaire (SF-LDQ) before taking the first dose of regimens, at the end of therapy, and also 4 weeks after (follow-up). Results The mean age in Group A (n = 83) was 48.55 ± 12.56 and 47.24 ± 12.78 in Group B (n = 79). No statistically significant differences were observed between the two groups regarding age, gender, endoscopic findings, and also eradication rate. The analysis demonstrated a significant decrease in SF-LDQ score between baseline and after therapy and baseline and follow-up in both regimen groups. Both regimens were well tolerated by the majority of patients, and there were no significant differences between the two groups in terms of adverse drug reactions. Conclusion This study showed that ST can be used as an alternative first-line therapy to QT in patients with H. pylori infection.
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Affiliation(s)
- Elham Tabesh
- Gastroenterology and Hepatology Research CenterIsfahan University of Medical SciencesIsfahanIran
| | - Farzad Yadmehr
- Department of Infectious Diseases, School of MedicineIsfahan University of Medical SciencesIsfahanIran
| | - Awat Feizi
- Department of Biostatistics and Epidemiology, School of HealthIsfahan University of Medical SciencesIsfahanIran
| | - Farzin Khorvash
- Nosocomial Infection Research CenterIsfahan University of Medical SciencesIsfahanIran
| | - Setayesh Sindarreh
- Cancer Prevention Research CenterIsfahan University of Medical SciencesIsfahanIran
| | - Atousa Hakamifard
- Department of Infectious Diseases, School of MedicineIsfahan University of Medical SciencesIsfahanIran
- Cancer Prevention Research CenterIsfahan University of Medical SciencesIsfahanIran
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Dascălu RI, Bolocan A, Păduaru DN, Constantinescu A, Mitache MM, Stoica AD, Andronic O. Multidrug resistance in Helicobacter pylori infection. Front Microbiol 2023; 14:1128497. [PMID: 36922977 PMCID: PMC10009102 DOI: 10.3389/fmicb.2023.1128497] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/30/2023] [Indexed: 03/02/2023] Open
Abstract
Helicobacter pylori (Hp), a well-known human pathogen, causes one of the most common chronic bacterial infections and plays an important role in the emergence of chronic progressive gastric inflammation and a variety of gastrointestinal diseases. The prevalence of Hp infection varies worldwide and is indirectly proportional to socio-economic status, especially during childhood. The response to the eradication therapy significantly depends on the antibiotic resistance specific to each geographical region; thus, currently, given the increasing prevalence of antimicrobial resistance (especially to clarithromycin, metronidazole, and levofloxacin), successful treatment for Hp eradication has become a real challenge and a critical issue. The most incriminated factors associated with multidrug resistance (MDR) in Hp proved to be the overuse or the improper use of antibiotics, poor medication adherence, and bacterial-related factors including efflux pumps, mutations, and biofilms. Up to 30% of first-line therapy fails due to poor patient compliance, high gastric acidity, or high bacteremia levels. Hence, it is of great importance to consider new eradication regimens such as vonoprazan-containing triple therapies, quintuple therapies, high-dose dual therapies, and standard triple therapies with probiotics, requiring further studies and thorough assessment. Strain susceptibility testing is also necessary for an optimal approach.
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Affiliation(s)
| | - Alexandra Bolocan
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,University Emergency Hospital of Bucharest, Bucharest, Romania
| | - Dan Nicolae Păduaru
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,University Emergency Hospital of Bucharest, Bucharest, Romania
| | - Alexandru Constantinescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,University Emergency Hospital of Bucharest, Bucharest, Romania
| | | | - Anca Daniela Stoica
- Babeş-Bolyai University, Cluj-Napoca, Romania.,National Institute for Research and Development of Isotopic and Molecular Technologies, Cluj-Napoca, Romania
| | - Octavian Andronic
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,University Emergency Hospital of Bucharest, Bucharest, Romania.,Research Institute of the University of Bucharest, Bucharest, Romania
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3
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Sathianarayanan S, V A, Biswas R, B A, Sukumaran S, Venkidasamy B. A new approach against Helicobacter pylori using plants and its constituents: A review study. Microb Pathog 2022. [DOI: 10.1016/j.micpath.2022.105594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 05/11/2022] [Accepted: 05/15/2022] [Indexed: 02/07/2023]
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4
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Mestrovic A, Perkovic N, Bozic J, Pavicic Ivelja M, Vukovic J, Kardum G, Puljiz Z, Tonkic A. Randomised clinical trial comparing concomitant and hybrid therapy for eradication of Helicobacter pylori infection. PLoS One 2020; 15:e0244500. [PMID: 33378403 PMCID: PMC7773256 DOI: 10.1371/journal.pone.0244500] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 12/09/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The primary objective of this study was to compare concomitant and hybrid therapy in the first line eradication treatment of Helicobacter pylori infection in Split-Dalmatia County, Croatia, in which clarithromycin resistance is above 20%. The secondary objective of the study was to determine and compare compliance and adverse events rate between these therapeutic protocols. MATERIALS AND METHODS In an open-label, randomised clinical trial 140 patients total with H. pylori infection were randomly assigned to either concomitant (esomeprazole 40 mg, amoxicillin 1 g, metronidazole 500 mg, clarithromycin 500 mg, twice daily for 14 days) or hybrid (esomeprazole 40 mg and amoxicillin 1 g twice daily during 14 days with adding metronidazole 500 mg and clarithromycin 500 mg twice daily, in the last 7 days,) treatment group. RESULTS Eradication rates for concomitant group and hybrid therapy group were 84.1% (58/69) and 83.1% (59/71) respectively in the intention-to-treat analysis and 96.7% (58/60) and 95.2% (59/62) in per-protocol analysis. There was no significant difference between the groups (ITT analysis: P = 0.878; PP analysis: P = 0.675). Adverse events were more frequent in the concomitant group (33.3% vs 18.3%, P = 0.043). There was no difference among groups regarding compliance rate. CONCLUSION Hybrid therapy has similar eradication rate as concomitant therapy, with lower adverse events rate. In the era of increasing antibiotic resistance, eradication regime with less antibiotic's usage, as hybrid therapy, should be reasonable first line treatment choice for H. pylori infection. Clinical Trials, gov: NCT03572777.
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Affiliation(s)
- Antonio Mestrovic
- Department of Gastroenterology, University Hospital of Split, Split, Croatia
- * E-mail:
| | - Nikola Perkovic
- Department of Gastroenterology, University Hospital of Split, Split, Croatia
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia
| | | | - Jonatan Vukovic
- Department of Gastroenterology, University Hospital of Split, Split, Croatia
| | - Goran Kardum
- Department of Psychology, Faculty of Humanities and Social Sciences, University of Split, Split, Croatia
| | - Zeljko Puljiz
- Department of Gastroenterology, University Hospital of Split, Split, Croatia
- Department of Internal Medicine, University of Split School of Medicine, Split, Croatia
| | - Ante Tonkic
- Department of Gastroenterology, University Hospital of Split, Split, Croatia
- Department of Internal Medicine, University of Split School of Medicine, Split, Croatia
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5
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Abstract
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.
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Affiliation(s)
- Sotirios Georgopoulos
- Department of Gastroenterology, Athens Medical P. Faliron General Hospital, Athens, Greece
| | - Vasilios Papastergiou
- Department of Gastroenterology, "Konstantopoulion-Patision" General Hospital, Athens, Greece
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Gudra D, Pupola D, Skenders G, Leja M, Radovica-Spalvina I, Gorskis H, Vangravs R, Fridmanis D. Lack of significant differences between gastrointestinal tract microbial population structure of Helicobacter pylori-infected subjects before and 2 years after a single eradication event. Helicobacter 2020; 25:e12748. [PMID: 32776403 DOI: 10.1111/hel.12748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND According to recent estimates 80% of Latvian population is infected with Helicobacter pylori thus their susceptibility to numerous gastric tract diseases is increased. The 1st line H. pylori eradication therapy includes treatment with clarithromycin in combination with amoxicillin or metronidazole and a proton pump inhibitor. However, potential adverse events caused by such therapies to microbiome are insufficiently studied. OBJECTIVE This study aimed to evaluate the long-term effect of H. pylori eradication on human gastrointestinal tract (GIT) microbiome. METHODS The assessment of H pylori eradication impact on GIT microbiome was done by analyzing 120 samples acquired from 60 subjects. Each individual was prescribed the following 10-day eradication regimen: Esomeprazolum 40 mg, Clarithromycinum 500 mg, and Amoxicillinum 1000 mg, BID. Samples from each individual were collected before starting H pylori eradication therapy, and 2 years after the completion of the therapy in OC-Sensor (Eiken Chemical Co.) sample collection containers and stored at -86°C. Prior to DNA extraction, the samples were lyophilized, and total DNA was extracted using FastDNA Spin Kit for Soil. 16S V3 rRNA gene sequencing was done employing Ion Torrent PGM, and the obtained raw sequences were analyzed using vsearch and R (phyloseq, cluster packages). RESULTS Alpha diversity measurements-observed OTUs, Chao1 and Shannon index did not differ significantly between the pre- and post-eradication states (two-tailed paired t test: P = .95; P = .71, P = .24, respectively). Unweighted and weighted UniFrac distances of beta diversity analysis indicated a non-specific pattern of sample clustering. Enterotype shift was observed for the majority of individuals comparing pre- and post-eradication study groups. Association analysis revealed that certain bacterial genera significantly correlated with age (eg, Dialister, Paraprevotella, Bifidobacterium), individual (eg, Thermotunica, Streptomyces, Faecalibacterium), and history of respiratory and/or allergic diseases (eg, Colinsella, Faecalibacterium). Redundancy analysis confirmed that the individual was a significant determinant of the subject's microbial community composition (ANOVA, 999 perm., P = .001) with the further lower impact of subject-specific medical history (eg, medication used as prescribed: P = .005, history of cardiovascular diseases: P = .005, history of respiratory, and/or allergic diseases: P = .015) and physiological (eg, age: P = .005, gender: P = .02) parameters. In the post-eradication study group, number of influential genera (n = 260) was increased compared to the pre-eradication study group (n = 209). CONCLUSION Modest global differences at the community level exist between individuals before and after the eradication therapy; however, the microbiome structure is more related to the subject-specific parameters rather than by the eradication therapy itself.
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Affiliation(s)
- Dita Gudra
- Latvian Biomedical Research and Study Centre, Riga, Latvia
| | - Darta Pupola
- Institute of Clinical and Preventive Medicine, University of Latvia, Riga, Latvia
| | - Girts Skenders
- Institute of Clinical and Preventive Medicine, University of Latvia, Riga, Latvia
| | - Marcis Leja
- Institute of Clinical and Preventive Medicine, University of Latvia, Riga, Latvia.,Faculty of Medicine, University of Latvia, Riga, Latvia
| | | | - Henrihs Gorskis
- Institute of Clinical and Preventive Medicine, University of Latvia, Riga, Latvia
| | - Reinis Vangravs
- Institute of Clinical and Preventive Medicine, University of Latvia, Riga, Latvia
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7
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Apostolopoulos P, Ekmektzoglou K, Georgopoulos S, Chounta E, Theofanopoulou A, Kalantzis C, Vlachou E, Tsibouris P, Alexandrakis G. 10-Day Versus 14-Day Quadruple Concomitant Nonbismuth Therapy for the Treatment of Helicobacter pylori Infection: Results From a Randomized Prospective Study in a High Clarithromycin Resistance Country. J Clin Gastroenterol 2020; 54:522-7. [PMID: 32028286 DOI: 10.1097/MCG.0000000000001328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
GOALS The aim of this study was to investigate the implementation of a 14-day quadruple nonbismuth concomitant regimen, as proposed by recent Guidelines and Consensus Statements. BACKGROUND In Greece, a region with >20% clarithromycin resistance where bismuth is unavailable, the 10-day quadruple concomitant scheme has already been adopted as the accepted first-line Helicobacter pylori eradication treatment. STUDY Our prospective randomized study included 364 patients with newly diagnosed H. pylori infection, randomized to receive a 10-day or a 14-day nonbismuth quadruple concomitant scheme. Treatment outcome was assessed by C-urea breath test and/or histology at least 4 weeks after therapy. Intention to treat and per protocol analyses of the eradication rates were performed. Secondary endpoints included patient adherence, safety, and the impact of prior antibiotic exposure in treatment efficacy. RESULTS The overall eradication rates of the 2 treatments were 87.9% versus 87.4% in the intention to treat analysis, P=1.000, and 93% versus 94.1%, P=0.859, in the per protocol analysis for the 10-day and the 14-day treatment group, respectively. Both groups displayed excellent compliance rates (99.5% for the 10-day vs. 96.2% for the 14-day treatment duration, P=0.067). As regards treatment safety, serious adverse events that led to the discontinuation of both regimens were few, with no statistical difference between the 2 groups (0.5% in the 10-day group and 2.2% in the 14-day group, P>0.05). Previous antibiotic exposure was not significant with regard to treatment efficacy. CONCLUSION In Greece, the 10-day concomitant nonbismuth quadruple regimen for first-line treatment remains the most efficient strategy for H. pylori eradication.
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8
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Liatsos C, Papaefthymiou A, Kyriakos N, Giakoumis M, Kountouras J, Galanopoulos M, Apostolopoulos P, Georgopoulos SD, Mavrogiannis C, Exadaktylos AK, Srivastava DS, Rokkas T, Doulberis M. Evaluation of the Direct Economic Cost per Eradication Treatment Regimen against Helicobacter pylori Infection in Greece: Do National Health Policy-Makers Need to Care? ACTA ACUST UNITED AC 2020; 56:E133. [PMID: 32197498 DOI: 10.3390/medicina56030133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 12/15/2022]
Abstract
Helicobacter pylori (Hp) management has undoubtedly resulted in a notable economic burden on healthcare systems globally, including Greece. Its cost has never been estimated so far, especially during the recent 10-year unprecedented financial crisis. Direct medical and procedural costs for one attempt "outpatient" Hp eradication treatment were estimated as the following: (I) first-line regimens: 10 and 14 days standard triple, 10 and 14 days sequential, 10 and 14 days concomitant non-bismuth quadruple, 14 days hybrid, (II) second-line salvage regimens: 10 and 14 days levofloxacin-containing triple regimens. Treatment costs using prototypes and/or generic drugs were calculated. Drug prices were collected and confirmed from two official online medical databases including all medicines approved by the Greek National Organization for Medicines. Regimens based on generics were more affordable than prototypes and those including pantoprazole yielded the lowest prices (mean: 27.84 €). Paradoxically, 10-day concomitant and 14-day hybrid regimens (currently providing good (90-94%) first-line eradication rates in Greece) cost the same (mean: 34.76 €). The expenditures for Hp eradication treatment regimens were estimated thoroughly for the first time in Greece. These data should be taken into account by Public Health policymakers both in Greece and the European Union, aiming for a better and less expensive therapeutic approach.
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Papaefthymiou A, Liatsos C, Georgopoulos SD, Apostolopoulos P, Doulberis M, Kyriakos N, Giakoumis M, Papadomichelakis M, Galanopoulos M, Katsinelos P, Rokkas T, Kountouras J. Helicobacter pylori eradication regimens in an antibiotic high-resistance European area: A cost-effectiveness analysis. Helicobacter 2020; 25:e12666. [PMID: 31692137 DOI: 10.1111/hel.12666] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 10/04/2019] [Accepted: 10/04/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Helicobacter pylori infection (H pylori-I) affects more than half of the global population and consists an important burden to public health and healthcare expenditures, by contributing to many diseases' pathogenesis. AIM This study aimed to evaluate the current nonbismuth quadruple eradication regimens in a high antibiotic resistance area, such as Greece, concerning their cost-effectiveness, especially during financial crisis period. MATERIALS AND METHODS Eight hundred and nine patients who received eradication treatment against H pylori-I were included to evaluate five different regimens, using amoxicillin, clarithromycin, and metronidazole as antibiotics and one proton-pump inhibitor, based on their current eradication rates. Regimes compared 10-day concomitant use of (a) pantoprazole or (b) esomeprazole; 10-day sequential use of (c) pantoprazole or (d) esomeprazole; and 14-day hybrid using esomeprazole. Cost-effectiveness analysis ratio (CEAR) and incremental cost-effectiveness ratios were calculated taking into account all direct costs and cases who needed second-line treatment. Additionally, sensitivity analysis was performed to predict all potential combinations. RESULTS Ten-day concomitant regimen with esomeprazole was characterized by the lowest CEAR (179.17€) followed by the same regimen using pantoprazole (183.27€). Hybrid regimen, although equivalent in eradication rates, was found to have higher CEAR (187.42€), whereas sequential regimens were not cost-effective (CEAR: 204.12€ and 216.02€ respectively). DISCUSSION This is the first study evaluating the cost-effectiveness of H pylori-I treatment regimens in a high clarithromycin-resistance (≈26.5%) European area, suggesting the 10-day concomitant regimen with generics using esomeprazole 40 mg as the most appropriate one. National and regional guidelines should include cost-effectiveness in their statements, and further studies are required to clarify the necessity of a wide "test and treat" policy for H pylori-I.
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Affiliation(s)
| | - Christos Liatsos
- Department of Gastroenterology, 401 Army General Hospital of Athens, Athens, Greece
| | | | | | - Michael Doulberis
- Department of Gastroenterology and Hepatology, University of Zurich, Zurich, Switzerland.,Department of Medicine, Second Medical Clinic, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece
| | - Nikolaos Kyriakos
- Department of Gastroenterology, 401 Army General Hospital of Athens, Athens, Greece
| | - Marios Giakoumis
- Department of Gastroenterology, 401 Army General Hospital of Athens, Athens, Greece
| | | | - Michail Galanopoulos
- Department of Gastroenterology, 401 Army General Hospital of Athens, Athens, Greece
| | - Panagiotis Katsinelos
- Department of Medicine, Second Medical Clinic, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece
| | - Theodore Rokkas
- Gastroenterological Clinic, Henry Dunant Hospital, Athens, Greece
| | - Jannis Kountouras
- Department of Medicine, Second Medical Clinic, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece
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Georgopoulos SD, Michopoulos S, Rokkas T, Apostolopoulos P, Giamarellos E, Kamberoglou D, Mentis A, Triantafyllou K. Hellenic consensus on Helicobacter pylori infection. Ann Gastroenterol 2020; 33:105-124. [PMID: 32127732 PMCID: PMC7049243 DOI: 10.20524/aog.2020.0446] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/30/2019] [Indexed: 02/06/2023] Open
Abstract
The Hellenic Society of Gastroenterology recently organized the “Hellenic consensus on Helicobacter pylori (H. pylori) infection”. The aim of this publication is to report the guidelines in order to aid the national gastroenterology community in the management of H. pylori infection. Forty-one delegates from all Greek regions, including gastroenterologists, pathologists, clinical microbiologists, epidemiologists and basic scientists, were invited to this meeting. The participants were allocated to 1 of the 4 main topics of the meeting: i.e., H. pylori diagnosis and association with diseases; H. pylori and gastric cancer; H. pylori and extragastric associated disorders; and H. pylori treatment. The results of each subgroup were submitted to a final consensus vote that included all participants. Relevant data based on international and Greek publications were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded. The cutoff level of 70% was considered as acceptance for the final statement. It is hoped that the recommendations and conclusions of this report will guide Greek doctors in their daily practice concerning the management of H. pylori infection.
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Affiliation(s)
| | | | - Theodoros Rokkas
- Gastroenterology Department, Henry Dynan Hospital (Theodoros Rokkas)
| | | | - Evangelos Giamarellos
- 4 Department of Internal Medicine, Attikon University Hospital (Evangelos Giamarellos)
| | | | - Andreas Mentis
- Laboratory of Medical Microbiology, Hellenic Pasteur Institute, (Andreas Mentis)
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11
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Savoldi A, Carrara E, Graham DY, Conti M, Tacconelli E. Prevalence of Antibiotic Resistance in Helicobacter pylori: A Systematic Review and Meta-analysis in World Health Organization Regions. Gastroenterology 2018; 155:1372-1382.e17. [PMID: 29990487 PMCID: PMC6905086 DOI: 10.1053/j.gastro.2018.07.007] [Citation(s) in RCA: 644] [Impact Index Per Article: 107.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 06/27/2018] [Accepted: 07/05/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS In 2017, the World Health Organization (WHO) designated clarithromycin-resistant Helicobacter pylori a high priority for antibiotic research and development. However, there are no clear data on the global distribution of resistance or its clinical effects. We performed a systematic review and meta-analysis to assess the distribution of H pylori resistance to commonly used antibiotics and to measure the association between antibiotic resistance and treatment failure. METHODS We searched publication databases for studies that assessed rates of H pylori resistance to clarithromycin, metronidazole, levofloxacin, amoxicillin, or tetracycline. Pooled estimates of primary and secondary resistance and 95% confidence intervals (CIs) were grouped by WHO region. The association between antibiotic resistance and treatment failure was measured by extracting data on treatment efficacy in patients with resistant and susceptible isolates and pooling odds ratios with 95% CIs. RESULTS We identified 178 studies, comprising 66,142 isolates from 65 countries. Primary and secondary resistance rates to clarithromycin, metronidazole, and levofloxacin were ≥15% in all WHO regions, except primary clarithromycin resistance in the Americas (10%; 95% CI, 4%-16%) and South-East Asia region (10%; 95% CI, 5%-16%) and primary levofloxacin resistance in the European region (11%; 95% CI, 9%-13%). There was considerable heterogeneity (I2 > 75%) among all analyses-this might have resulted from the grouping of resistance rates by country. Increasing antibiotic resistance was observed in most WHO regions. Resistance to clarithromycin was significantly associated with failure of clarithromycin-containing regimens (odds ratio, 6.97; 95% CI, 5.23-9.28; P < .001). CONCLUSIONS Resistance of H pylori to antibiotics has reached alarming levels worldwide, which has a great effect on efficacy of treatment. Local surveillance networks are required to select appropriate eradication regimens for each region.
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Affiliation(s)
- Alessia Savoldi
- Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Tübingen, Germany
| | - Elena Carrara
- Division of Infectious Diseases, Department of Diagnostic and Public Health, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - David Y Graham
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Michela Conti
- Division of Infectious Diseases, Department of Diagnostic and Public Health, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Tübingen, Germany; Division of Infectious Diseases, Department of Diagnostic and Public Health, G.B. Rossi University Hospital, University of Verona, Verona, Italy.
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12
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Hajiani E, Alavinejad P, Avandi N, Masjedizadeh AR, Shayesteh AA. Comparison of Levofloxacin-Based, 10-day Sequential Therapy with 14-day Quadruple Therapy for Helicobacter Pylori Eradication: A Randomized Clinical Trial. Middle East J Dig Dis 2018; 10:242-248. [PMID: 31049172 PMCID: PMC6488509 DOI: 10.15171/mejdd.2018.117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 09/02/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND
Considering the importance of Helicobacter pylori (H. pylori) eradication, this clinical trial
was designed to prospectively evaluate the efficacy of levofloxacin-based, sequential therapy in
comparison with quadruple therapy for eradicating H. pylori.
METHODS
Overall 156 patients with dyspepsia and H. pylori infection were included in this study and
were randomly allocated to either 10-day sequential therapy group (group A) to receive pantoprazole
(40 mg twice daily), amoxicillin (1 gr twice daily), levofloxacin (500 mg twice daily), and
tinidazole (500 mg twice daily) (PALT) or 14-day quadruple therapy group (group B) to receive
pantoprazole, clarithromycin, bismuth subcitrate, and amoxicillin (PABC). At the end of the study
the eradication rate in each group was assessed by urea breath test (UBT).
RESULTS
Age range of the participants was 18-65 years (average 36.9 years) and 50% of them (78
patients) were men. 78 patients were allocated to group A and 78 patients to groupe B. After antibiotic
therapy, all the patients received acid suppression therapy with Proton Pump Inhibitor (PPI)
for 4 weeks and then the eradication rate was confirmed by UBT (Heli FAN plus 13C, Germany).
Before performing UBT, all the participants were requested to halt consumption of PPI for at least
1 week. During the treatment there was not any major complication but in group A (sequential
therapy), two patients complained of minor complications including musculoskeletal pain. None
of the patients in group B had any complaint or side effect.
The rate of H. pylori eradication in group A was 78.2% (61 patients) while this rate in group B was
83.3% (65 patients) with no significant difference between the two groups (p = 0.42). In subgroup
analysis, the rate of eradication among men in group A and B were 76.9% and 89.7%, respectively
(p = 0.22) while the eradication rate among women were 79.4% and 76.9%, respectively (p = 1.00).
CONCLUSION
It seems that levofloxacin base sequential therapy does not have any advantage in comparison
with quadruple regimen and until finding any more effective short course therapy for H. Pylori
eradication; we encourage quadruple regimen to be used as the first line therapy.
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Affiliation(s)
- Eskandar Hajiani
- Alimentary Tract Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Pezhman Alavinejad
- Alimentary Tract Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nahid Avandi
- Medical Faculty, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | - Ali Akbar Shayesteh
- Alimentary Tract Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Park HS, Wijerathne CUB, Jeong HY, Seo CS, Ha H, Kwun HJ. Gastroprotective effects of Hwanglyeonhaedok-tang against Helicobacter pylori-induced gastric cell injury. J Ethnopharmacol 2018; 216:239-250. [PMID: 29410309 DOI: 10.1016/j.jep.2018.01.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 06/07/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Helicobacter pylori, which is found in the stomachs of approximately half of the world's population, has been associated with the development of chronic gastritis and gastric cancer. Hwanglyeonhaedok-tang (HHT) is a popular traditional medicine for the therapies of gastric ulcers and gastritis. AIM OF THE STUDY The emerging resistance of H. pylori to antibiotics arouses requirement on alternative nonantibiotic-based therapies. In the present study, we investigated the anti-inflammatory activity and anti-microbial activity of HHT against H. pylori in vitro and in an H. pylori-infected mouse model. MATERIALS AND METHODS H. pylori were treated with various concentrations of HHT and then incubated with human gastric carcinoma AGS cells. For the in vivo study, mice were orally infected with H. pylori three times over the course of 1 week, and then subjected to daily administration of HHT (120 or 600 mg/kg) for 4 weeks or standard triple therapy for 1 week. At the scheduled termination of the experiment, all mice were killed and their stomachs were collected for histological examination, quantitative real-time PCR, and Western blot analysis. RESULTS Our in vitro studies showed that HHT treatment inhibited the adhesion of H. pylori to AGS cells and suppressed the H. pylori-induced increases of inflammatory regulators, such as interleukin (IL)-8, cyclooxygenase 2 (COX-2), and inducible nitric oxide synthase (iNOS). In the mouse model, HHT treatment significantly reduced H. pylori colonization, inflammation, and the levels of IL-1β, IL-6, C-X-C motif chemokine ligand 1 (CXCL1), tumor necrosis factor alpha (TNF-α), COX-2, and iNOS in gastric mucosa. Further investigation showed that HHT treatment reduced the H. pylori-induced phosphorylations of p38 mitogen-activated protein kinase (MAPK), extracellular signal-regulated kinases 1/2 (ERK1/2), c-Jun N-terminal protein kinase (JNK), and nuclear factor-kappa B (NF-κB). CONCLUSIONS Our findings collectively suggest that HHT has anti-inflammatory activity and antibacterial activity against H. pylori and could be an alternative to antibiotics for preventing H. pylori infection.
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Affiliation(s)
- Hee-Seon Park
- Department of Veterinary Pathology, College of Veterinary Medicine, Chungnam National University, Daejeon, Republic of Korea..
| | - Charith U B Wijerathne
- Department of Veterinary Pathology, College of Veterinary Medicine, Chungnam National University, Daejeon, Republic of Korea..
| | - Hye-Yun Jeong
- Department of Veterinary Pathology, College of Veterinary Medicine, Chungnam National University, Daejeon, Republic of Korea..
| | - Chang-Seob Seo
- K-herb Research Center, Korea Institute of Oriental Medicine, Daejeon, Republic of Korea..
| | - Hyekyung Ha
- K-herb Research Center, Korea Institute of Oriental Medicine, Daejeon, Republic of Korea..
| | - Hyo-Jung Kwun
- Department of Veterinary Pathology, College of Veterinary Medicine, Chungnam National University, Daejeon, Republic of Korea..
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Tursi A, Franceschi M, Allegretta L, Savarino E, De Bastiani R, Elisei W, Baldassarre G, Ferronato A, Scida S, Miraglia C, Penna A, Licci C, Rizzo GL, Pranzo G, Cassieri C, Brandimarte G, Picchio M, Di Mario F. Effectiveness and Safety of Pylera® in Patients Infected by Helicobacter Pylori: A Multicenter, Retrospective, Real Life Study. Dig Dis 2018; 36:264-268. [PMID: 29669354 DOI: 10.1159/000487391] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 01/30/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Our aims were to assess the real life effectiveness and safety of the new bismuth-containing quadruple therapy in a large population of patients infected by Helicobacter pylori. METHODS Consecutive dyspeptic H. pylori-positive patients were enrolled, both naïve for treatment and already unsuccessfully treated. Patients were treated with Pylera® 3 capsules 4 times/daily plus omeprazole 20 mg or esomeprazole 40 mg 2 times/daily for 10 days. Eradication was confirmed using a urea-breath test (at least 30 days after the end of the treatment). Efficacy and safety were assessed. RESULTS A total of 349 patients were treated. H. pylori eradication was achieved in 316 (90.5%, 95% CIs 80.8-1.0) patients in the intention-to-treat population, and in 93.5% (95% CIs 83.5-1.0) in the per-protocol population. No difference in the eradication rate was found between naïve and previously treated patients (91.3 vs. 90.0%, p = 0.901). Adverse events occurred in 55 patients (15.8%, 95% CIs 11.9-20.1). Five patients discontinued treatment: 2 patients suffered from severe abdominal pain, one patient from headache, one patient from diarrhea, and one patient from diffuse urticarial rush. CONCLUSIONS Pylera® achieved a remarkable eradication rate in real life both as first treatment and as a rescue therapy, with a good safety profile.
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Affiliation(s)
| | | | - Leonardo Allegretta
- Division of Gastroenterology, "S. Caterina Novella" Hospital, Galatina, Italy
| | - Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Rudi De Bastiani
- Italian Association for Gastroenterology in Primary Care (GICA-CP), Feltre, Italy
| | | | | | | | - Serena Scida
- Department of Clinical and Experimental Medicine, Gastroenterology Unit, University of Parma, Parma, Italy
| | - Chiara Miraglia
- Department of Clinical and Experimental Medicine, Gastroenterology Unit, University of Parma, Parma, Italy
| | - Antonio Penna
- Division of Gastroenterology, "S. Paolo" Hospital, Bari, Italy
| | - Claudio Licci
- Private Practice Gastroenterologist, Monopoly, Italy
| | | | - Giuseppe Pranzo
- Digestive Endoscopy Service, "Valle d'Itria" Hospital, Martina Franca, Italy
| | - Claudio Cassieri
- Division of Internal Medicine and Gastroenterology, "Cristo Re" Hospital, Rome, Italy
| | - Giovanni Brandimarte
- Division of Internal Medicine and Gastroenterology, "Cristo Re" Hospital, Rome, Italy
| | | | - Francesco Di Mario
- Department of Clinical and Experimental Medicine, Gastroenterology Unit, University of Parma, Parma, Italy
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15
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Georgopoulos SD, Papastergiou V, Martinez-Gonzalez B, Xirouchakis E, Familias I, Sgouras D, Mentis A, Karatapanis S. Hybrid therapy as first-line regimen for Helicobacter pylori eradication in a high clarithromycin resistance area: a prospective open-label trial. Ann Gastroenterol 2018; 31:205-210. [PMID: 29507467 PMCID: PMC5825950 DOI: 10.20524/aog.2017.0221] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 10/26/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hybrid therapy is a promising first-line regimen for Helicobacter pylori (H. pylori) eradication. We evaluated a hybrid therapy, assessing the impact of antibiotic resistance on eradication outcome. METHODS This was a prospective study that included 155 treatment-naïve patients diagnosed with H. pylori infection by positive CLO-test, confirmed with histology and/or culture. The hybrid therapy consisted of 40 mg esomeprazole and 1 g amoxicillin for 14 days, with the addition of 500 mg clarithromycin and 500 mg metronidazole for the final 7 days (all b.i.d.). Eradication was defined by negative 13C-urea breath test or histology. RESULTS The eradication rates were 85.8% (133/155; 95% confidence interval [CI] 79.4-90.5%) by intention-to-treat and 90.2% (129/143; 95%CI 84.1-94.2%) by per-protocol analysis in a setting of high antibiotic resistance (clarithromycin 25.9%, metronidazole 31.1%, dual resistance 8.9%). Adverse events occurred in 29.7% and 1.3% discontinued treatment because of adverse events. Adherence >90% was achieved in 96.6%. The eradication rate in patients with dual clarithromycin/metronidazole resistance (50%) was markedly lower compared to those with single clarithromycin resistance (91.4%), single metronidazole resistance (90.5%) or dual susceptibility (97.8%). Dual resistance was the only factor to correlate with the failure of hybrid therapy (odds ratio 14.4, 95%CI 3.8-54.9, P=0.0003). CONCLUSIONS Hybrid therapy is an effective and safe first-line regimen in populations with relatively high rates of antibiotic resistance. However, dual clarithromycin/metronidazole resistance may significantly compromise its efficacy.
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Affiliation(s)
- Sotirios D. Georgopoulos
- Gastroenterology Department, Athens Medical, Paleo Faliron Hospital, Athens (Sotirios D. Georgopoulos, Elias Xirouchakis), Greece
| | - Vasilios Papastergiou
- First Department of Internal Medicine, General Hospital of Rhodes, Rhodes (Vasilios Papastergiou, Ioannis Familias, Stylianos Karatapanis), Greece
| | - Beatriz Martinez-Gonzalez
- Laboratory of Medical Microbiology, Hellenic Pasteur Institute, Athens (Beatriz Martinez-Gonzalez, Dionysis Sgouras, Andreas Mentis), Greece
| | - Elias Xirouchakis
- Gastroenterology Department, Athens Medical, Paleo Faliron Hospital, Athens (Sotirios D. Georgopoulos, Elias Xirouchakis), Greece
| | - Ioannis Familias
- First Department of Internal Medicine, General Hospital of Rhodes, Rhodes (Vasilios Papastergiou, Ioannis Familias, Stylianos Karatapanis), Greece
| | - Dionysis Sgouras
- Laboratory of Medical Microbiology, Hellenic Pasteur Institute, Athens (Beatriz Martinez-Gonzalez, Dionysis Sgouras, Andreas Mentis), Greece
| | - Andreas Mentis
- Laboratory of Medical Microbiology, Hellenic Pasteur Institute, Athens (Beatriz Martinez-Gonzalez, Dionysis Sgouras, Andreas Mentis), Greece
| | - Stylianos Karatapanis
- First Department of Internal Medicine, General Hospital of Rhodes, Rhodes (Vasilios Papastergiou, Ioannis Familias, Stylianos Karatapanis), Greece
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16
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Papastergiou V, Mathou N, Licousi S, Evgenidi A, Paraskeva KD, Giannakopoulos A, Stavrou PZ, Platsouka E, Karagiannis JA. Seven-day genotypic resistance-guided triple Helicobacter pylori eradication therapy can be highly effective. Ann Gastroenterol 2018; 31:198-204. [PMID: 29507466 PMCID: PMC5825949 DOI: 10.20524/aog.2017.0219] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 10/30/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The efficacy and applicability of molecular testing to guide the selection of antibiotics in triple Helicobacter pylori (H. pylori) eradication regimens have not been reported. We tested a 7-day, genotypic resistance-guided triple H. pylori eradication therapy in a high-resistance setting. METHODS Consecutive dyspeptic patients with H. pylori infection were prospectively enrolled. Genotypic resistances to clarithromycin (23SrRNA mutations) and fluoroquinolones (gyrA mutations) were determined from gastric biopsy specimens using a commercially available molecular assay (GenoTypeâ HelicoDR). A tailored genotypic resistance-guided 7-day triple therapy comprised esomeprazole, amoxicillin, and either clarithromycin (wild-type 23SrRNA), levofloxacin (23SrRNA mutated/wild-type gyrA) or rifabutin (both 23SrRNA/gyrA mutated). H. pylori eradication was confirmed by 13C-urea breath test. RESULTS Of 148 subjects screened, 51 patients were enrolled (male/female: 27/24, mean age: 50.7±11.4 years, treatment-naïve/-experienced: 32/19). The molecular kit was easily implemented, allowing for rapid (within 24 h) and relatively inexpensive determination of H. pylori resistance (clarithromycin: 47.1%, fluoroquinolones: 15.7%, dual clarithromycin/fluoroquinolones: 7.8%). For patients who received clarithromycin-, levofloxacin- and rifabutin-containing triple therapy, the respective eradication rates were 24/27, 20/20, and 2/4 by intention-to-treat (ITT); and 24/24, 19/19 and 2/3 by per-protocol (PP) analysis. Overall eradication rates were 90.2% (95% confidence interval [CI] 77.8-96.3%) by ITT and 97.8% (95%CI 87-99.8%) by PP analysis, showing no significant difference between treatment-naïve and -experienced patients (ITT: 87.5% vs. 94.7%, P=0.64; PP: 96.4% vs. 100%, respectively, P=1.00). CONCLUSIONS Regardless of prior treatment history, a genotypic resistance-guided 7-day triple therapy, based on a simple molecular assay, achieved a high H. pylori eradication rate.
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Affiliation(s)
- Vasilios Papastergiou
- Department of Gastroenterology (Vasilios Papastergiou, Nicoletta Mathou, Aikaterini Evgenidi, Konstantina D. Paraskeva, Athanasios Giannakopoulos, Pinelopi-Zoi Stavrou, John A. Karagiannis), Athens, Greece
| | - Nicoletta Mathou
- Department of Gastroenterology (Vasilios Papastergiou, Nicoletta Mathou, Aikaterini Evgenidi, Konstantina D. Paraskeva, Athanasios Giannakopoulos, Pinelopi-Zoi Stavrou, John A. Karagiannis), Athens, Greece
| | - Sophia Licousi
- Department of Microbiology (Sophia Licousi, Evangelia Platsouka), General Hospital of Nea Ionia “Konstantopouleio-Patission”, Athens, Greece
| | - Aikaterini Evgenidi
- Department of Gastroenterology (Vasilios Papastergiou, Nicoletta Mathou, Aikaterini Evgenidi, Konstantina D. Paraskeva, Athanasios Giannakopoulos, Pinelopi-Zoi Stavrou, John A. Karagiannis), Athens, Greece
| | - Konstantina D. Paraskeva
- Department of Gastroenterology (Vasilios Papastergiou, Nicoletta Mathou, Aikaterini Evgenidi, Konstantina D. Paraskeva, Athanasios Giannakopoulos, Pinelopi-Zoi Stavrou, John A. Karagiannis), Athens, Greece
| | - Athanasios Giannakopoulos
- Department of Gastroenterology (Vasilios Papastergiou, Nicoletta Mathou, Aikaterini Evgenidi, Konstantina D. Paraskeva, Athanasios Giannakopoulos, Pinelopi-Zoi Stavrou, John A. Karagiannis), Athens, Greece
| | - Pinelopi-Zoi Stavrou
- Department of Gastroenterology (Vasilios Papastergiou, Nicoletta Mathou, Aikaterini Evgenidi, Konstantina D. Paraskeva, Athanasios Giannakopoulos, Pinelopi-Zoi Stavrou, John A. Karagiannis), Athens, Greece
| | - Evangelia Platsouka
- Department of Microbiology (Sophia Licousi, Evangelia Platsouka), General Hospital of Nea Ionia “Konstantopouleio-Patission”, Athens, Greece
| | - John A. Karagiannis
- Department of Gastroenterology (Vasilios Papastergiou, Nicoletta Mathou, Aikaterini Evgenidi, Konstantina D. Paraskeva, Athanasios Giannakopoulos, Pinelopi-Zoi Stavrou, John A. Karagiannis), Athens, Greece
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17
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Ji Y, Lu H. Meta-analysis: High-dose vs. low-dose metronidazole-containing therapies for Helicobacter pylori eradication treatment. PLoS One 2018; 13:e0189888. [PMID: 29370199 PMCID: PMC5784897 DOI: 10.1371/journal.pone.0189888] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 12/04/2017] [Indexed: 01/06/2023] Open
Abstract
Objective The purpose of this study was to evaluate the efficacy of high dose of metronidazole in the treatment of Helicobacter pylori (H. pylori) infection. Methods Studies were identified from databases (Pubmed, Embase, Cochrane Library, ClinicalTrials.gov) searched from January 1990 to September 2017 using a battery of keywords. We included randomized controlled trials (RCTs) of H. pylori treatment comparing the high-dose and low-dose metronidazole-containing therapies (high-dose and low-dose therapies). Two reviewers independently selected studies, extracted relevant data and assessed study quality. A meta-analysis was performed by using Review Manager 5.3. Dichotomous data were pooled to obtain the relative risk (RR) of the eradication rate, with 95% confidence intervals (CIs). Results Four randomized controlled trials, a total of 612 patients with a diagnosis of H. pylori infection were included. Overall the meta-analysis showed that both high-dose and low-dose therapies achieved similar efficacy of intention-to-treat (ITT) eradication rate 82% vs. 76%, RR 1.12 (95%CI: 0.96 to 1.30), P = 0.15, and adherence 94% vs. 94%, RR 1.00 (95%CI: 0.97 to 1.04), P = 0.81, but side effects were more likely in high-dose therapies [32% vs. 17%, RR 1.84 (95%CI: 1.17 to 2.88), P = 0.008]. In subgroup analysis, increasing the dose of metronidazole enhanced eradication rates in areas with high metronidazole resistance [74% vs 52%, RR 1.40 (95%CI: 1.08 to 1.82), P = 0.01] and in individuals with metronidazole-resistant strains [71% vs. 46%, RR 1.50 (95%CI: 1.02 to 2.19), P = 0.04]. Conclusions Both high-dose and low-dose therapies can achieve similar eradication rates and adherence and generally low-dose therapies cause fewer side effects. In populations with high metronidazole resistance, high dose of metronidazole can increase the eradication rates of H. pylori infection.
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Affiliation(s)
- Yingjie Ji
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hong Lu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- * E-mail:
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18
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Tursi A, Di Mario F, Franceschi M, De Bastiani R, Elisei W, Baldassarre G, Ferronato A, Grillo S, Landi S, Zamparella M, De Polo M, Boscariolo L, Picchio M. New bismuth-containing quadruple therapy in patients infected with Helicobacter pylori: A first Italian experience in clinical practice. Helicobacter 2017; 22. [PMID: 28125857 DOI: 10.1111/hel.12371] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Rising antibiotic resistance requires the evaluation of new and effective therapies. AIMS To test the efficacy and safety of the new bismuth-containing quadruple therapy in patients infected with Helicobacter pylori. MATERIAL AND METHODS Consecutive H. pylori-positive dyspeptic patients were enrolled, either naïve or with previous failure treatment. Patients were treated with Pylera® (three-in-one capsules containing bismuth subcitrate potassium 140 mg, metronidazole 125 mg, and tetracycline 125 mg) three capsules q.i.d. plus omeprazole 20 mg or esomeprazole 40 mg b.i.d. for 10 days. Eradication was confirmed using an urea breath test (at least 30 days after the end of treatment). Efficacy was assessed by UBT and safety by means of treatment-emergent adverse events. RESULTS One hundred and thirty-one patients were included in the study: 42% of patients were naïve, and 58%, with previous failure treatment. H. pylori eradication was achieved in 124 patients (94.7%, 95% confidence intervals (CIs) 89.3-97.8) in ITT population. In the PP population, the percentage was 97.6% (95%, CIs 93.3-99.2). No difference in eradication rate was found either between naïve and previously treated patients (92.7% vs 96.0%, P=.383), or smoking and nonsmoking ones, or in patients taking omeprazole or esomeprazole. Treatment-emergent adverse events occurred in 35 patients (26.7%, 95% CIs 19.9-34.9). They were mild in all cases except in four, who discontinued the study due to diarrhea (three patients) and diffuse urticarial rush (one patient). CONCLUSIONS Pylera® achieved a remarkable eradication rate in clinical practice, irrespective if it was used as first treatment or as a rescue therapy. Treatment-emergent adverse events were uncommon generally mild.
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Affiliation(s)
- Antonio Tursi
- Gastroenterology Service, ASL BAT, Andria (BT), Italy
| | - Francesco Di Mario
- Department of Clinical & Experimental Medicine, Gastroenterology Unit, University of Parma, Parma, Italy
| | | | - Rudi De Bastiani
- Italian Association for Gastroenterology in Primary Care (GICA-CP), Feltre (BL), Italy
| | - Walter Elisei
- Division of Gastroenterology, ASL RM6, Albano Laziale (Roma), Italy
| | | | - Antonio Ferronato
- Digestive Endoscopy Unit, ULSS4 Alto Vicentino, Santorso, Schio (VI), Italy
| | - Simone Grillo
- Department of Clinical & Experimental Medicine, Gastroenterology Unit, University of Parma, Parma, Italy
| | - Stefano Landi
- Department of Clinical & Experimental Medicine, Gastroenterology Unit, University of Parma, Parma, Italy
| | - Maria Zamparella
- Italian Association for Gastroenterology in Primary Care (GICA-CP), Feltre (BL), Italy
| | - Manuela De Polo
- Italian Association for Gastroenterology in Primary Care (GICA-CP), Feltre (BL), Italy
| | - Laura Boscariolo
- Italian Association for Gastroenterology in Primary Care (GICA-CP), Feltre (BL), Italy
| | - Marcello Picchio
- Division of Surgery, "P. Colombo" Hospital, ASL RM6, Velletri (Rome), Italy
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19
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Hu Y, Zhu Y, Lu NH. Novel and Effective Therapeutic Regimens for Helicobacter pylori in an Era of Increasing Antibiotic Resistance. Front Cell Infect Microbiol 2017; 7:168. [PMID: 28529929 PMCID: PMC5418237 DOI: 10.3389/fcimb.2017.00168] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 04/18/2017] [Indexed: 01/06/2023] Open
Abstract
Helicobacter pylori (H. pylori) is a common gastrointestinal bacterial strain closely associated with the incidence of chronic gastritis, peptic ulcers, gastric mucosa-associated lymphoid tissue lymphoma, and gastric cancer. A current research and clinical challenge is the increased rate of antibiotic resistance in H. pylori, which has led to a decreased H. pylori eradication rate. In this article, we review recent H. pylori infection and reinfection rates and H. pylori resistance to antibiotics, and we discuss the pertinent treatments. A PubMed literature search was performed using the following keywords: Helicobacter pylori, infection, reinfection, antibiotic resistance, bismuth, proton pump inhibitors, vonoprazan, susceptibility, quintuple therapy, dual therapy, and probiotic. The prevalence of H. pylori has remained high in some areas despite the decreasing trend of H. pylori prevalence observed over time. Additionally, the H. pylori reinfection rate has varied in different countries due to socioeconomic and hygienic conditions. Helicobacter pylori monoresistance to clarithromycin, metronidazole or levofloxacin was common in most countries. However, the prevalence of amoxicillin and tetracycline resistance has remained low. Because H. pylori infection and reinfection present serious challenges and because H. pylori resistance to clarithromycin, metronidazole or levofloxacin remains high in most countries, the selection of an efficient regimen to eradicate H. pylori is critical. Currently, bismuth-containing quadruple therapies still achieve high eradication rates. Moreover, susceptibility-based therapies are alternatives because they may avoid the use of unnecessary antibiotics. Novel regimens, e.g., vonoprazan-containing triple therapies, quintuple therapies, high-dose dual therapies, and standard triple therapies with probiotics, require further studies concerning their efficiency and safety for treating H. pylori.
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Affiliation(s)
- Yi Hu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang UniversityNanchang, China
| | - Yin Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang UniversityNanchang, China
| | - Nong-Hua Lu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang UniversityNanchang, China
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20
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Malfertheiner P, Megraud F, O'Morain CA, Gisbert JP, Kuipers EJ, Axon AT, Bazzoli F, Gasbarrini A, Atherton J, Graham DY, Hunt R, Moayyedi P, Rokkas T, Rugge M, Selgrad M, Suerbaum S, Sugano K, El-Omar EM. Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report. Gut 2017; 66:6-30. [PMID: 27707777 DOI: 10.1136/gutjnl-2016-312288] [Citation(s) in RCA: 1757] [Impact Index Per Article: 251.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 08/09/2016] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- P Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - F Megraud
- Laboratoire de Bactériologie, Inserm U853, Université de Bordeaux, Bordeaux, France
| | - C A O'Morain
- Faculty of Health Sciences, Trinity College, Dublin, Ireland
| | - J P Gisbert
- Department of Gastroenterology, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - E J Kuipers
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - F Bazzoli
- Internal Medicine and Gastroenterology, University of Bologna Italy, Bologna, Italy
| | - A Gasbarrini
- Gastroenterology, and Liver Unit, Internal Medicine, Roma, Italy
| | | | - D Y Graham
- Department of Medicine (111D), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - R Hunt
- Department of Medicine, McMaster University, Hamilton, Canada.,Hillcroft, Beaconsfield, Buckinghamshire, UK
| | - P Moayyedi
- Department of Gastroenterology, McMaster University, Hamilton, Canada
| | - T Rokkas
- Department of Gastroenterology, Henry Dunant Hospital, Athens, Greece
| | - M Rugge
- Department of Diagnostic Sciences, University of Padova, Padova, Italy
| | | | - S Suerbaum
- Medizinische Hochschule Hannover, Institut für Medizinische Mikrobiologie, Hannover, Germany
| | - K Sugano
- Department of Medicine, Jichi Medical School, Tochigi, Japan
| | - E M El-Omar
- St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia
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21
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Hassan STS, Berchová K, Majerová M, Pokorná M, Švajdlenka E. In vitro synergistic effect of Hibiscus sabdariffa aqueous extract in combination with standard antibiotics against Helicobacter pylori clinical isolates. Pharm Biol 2016; 54:1736-40. [PMID: 26731378 DOI: 10.3109/13880209.2015.1126618] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 10/07/2015] [Accepted: 11/27/2015] [Indexed: 05/27/2023]
Abstract
Context The increasing problem of drug-resistant strains has led to the failure of current treatment regimens of Helicobacter pylori (HP) infection. Recently, a new treatment strategy has been developed to overcome the problem by using natural products in combination with antibiotics to enhance the treatment efficacy. Objective The antimicrobial combinatory effect of the aqueous extract of Hibiscus sabdariffa L. (Malvaceae) (AEHS) with antibiotics (clarithromycin, CLA; amoxicillin, AMX; metronidazole, MTZ) has been evaluated in vitro against HP strains. Materials and methods Hibiscus calyces (35 g) were brewed in 250 mL of boiled water for 30 min, and minimum inhibitory concentrations (MICs) were determined by agar dilution method. The checkerboard assay was used to evaluate the antimicrobial combinatory effect according to the sum of fractional inhibitory concentration (∑FIC) indices. Results In this study, AEHS exerted remarkable bacteriostatic effect against all HP strains tested with MICs values ranging from 9.18 to 16.68 μg/mL. Synergy effect of AEHS with CLA or MTZ was obtained against four of seven HP strains tested with ∑FIC ranging from 0.21 to 0.39. The additive effect of AEHS with AMX was obtained against five of seven HP strains tested with ∑FIC ranging from 0.61 to 0.91. Conclusion This study presents AEHS as a potent therapeutic candidate alone, or in combination with antibiotics for the treatment of HP infection.
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Affiliation(s)
- Sherif T S Hassan
- a Department of Natural Drugs , Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences Brno , Brno , Czech Republic
- b Department of Applied Ecology , Faculty of Environmental Sciences, Czech University of Life Sciences Prague , Praha , Suchdol , Czech Republic
| | - Kateřina Berchová
- b Department of Applied Ecology , Faculty of Environmental Sciences, Czech University of Life Sciences Prague , Praha , Suchdol , Czech Republic
| | - Michaela Majerová
- a Department of Natural Drugs , Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences Brno , Brno , Czech Republic
| | - Marie Pokorná
- a Department of Natural Drugs , Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences Brno , Brno , Czech Republic
| | - Emil Švajdlenka
- a Department of Natural Drugs , Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences Brno , Brno , Czech Republic
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22
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Apostolopoulos P, Koumoutsos I, Ekmektzoglou K, Dogantzis P, Vlachou E, Kalantzis C, Tsibouris P, Alexandrakis G. Concomitant versus sequential therapy for the treatment of Helicobacter pylori infection: a Greek randomized prospective study. Scand J Gastroenterol 2016; 51:145-51. [PMID: 26435055 DOI: 10.3109/00365521.2015.1079646] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The objective of this study is to compare, in Greece, a region with >20% local resistance to clarithromycin, the efficacy rates of the concomitant versus the sequential H. pylori eradication therapy. MATERIALS AND METHODS Our prospective randomized study included 364 patients with newly diagnosed H. pylori infection, randomized to receive a 10-day concomitant or 10-day sequential therapy. Treatment outcome was assessed by C(13)-urea breath test at least 4 weeks after therapy. Intention to treat (ITT) and per protocol (PP) analysis of the eradication rates were performed. Secondary end points included patient compliance and safety. RESULTS The concomitant therapy group achieved statistically significant higher eradication rates when compared with the sequential treatment group, both in the ITT and in the PP analysis (84.6% versus 70.9%, p = 0.002, and 90.6% versus 78.1%, p = 0.001, respectively), after adjusting for age, gender, smoking status, and the presence or not of ulcer and/or non-ulcer dyspepsia. Both groups displayed excellent compliance rates (99.5% for the concomitant therapy group and 96.2% for the sequential therapy group, p = 0.067). Regarding treatment safety, major adverse events that led to the discontinuation of both regimens were few, with no statistical difference between the two groups (7.0% for the concomitant therapy group and 2.9% for the sequential therapy group). CONCLUSIONS Concomitant therapy led to statistically significant higher eradication rates over sequential therapy. Both therapies showed excellent compliance and an acceptable safety profile. The 10-day quadruple concomitant scheme should be the adopted for first-line H. pylori eradication in Greece.
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Affiliation(s)
| | - Ioannis Koumoutsos
- a Department of Gastroenterology , Army Share Fund Hospital (NIMTS) , Athens , Greece
| | | | - Panagiotis Dogantzis
- a Department of Gastroenterology , Army Share Fund Hospital (NIMTS) , Athens , Greece
| | - Erasmia Vlachou
- a Department of Gastroenterology , Army Share Fund Hospital (NIMTS) , Athens , Greece
| | | | - Panagiotis Tsibouris
- a Department of Gastroenterology , Army Share Fund Hospital (NIMTS) , Athens , Greece
| | - Georgios Alexandrakis
- a Department of Gastroenterology , Army Share Fund Hospital (NIMTS) , Athens , Greece
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23
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Safavi M, Sabourian R, Foroumadi A. Treatment of Helicobacter pylori infection: Current and future insights. World J Clin Cases 2016; 4:5-19. [PMID: 26798626 PMCID: PMC4714294 DOI: 10.12998/wjcc.v4.i1.5] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/07/2015] [Accepted: 11/04/2015] [Indexed: 02/05/2023] Open
Abstract
Helicobacter pylori (H. pylori) is an important major cause of peptic ulcer disease and gastric malignancies such as mucosa-associated lymphoid tissue lymphoma and gastric adenocarcinoma worldwide. H. pylori treatment still remains a challenge, since many determinants for successful therapy are involved such as individual primary or secondary antibiotics resistance, mucosal drug concentration, patient compliance, side-effect profile and cost. While no new drug has been developed, current therapy still relies on different mixture of known antibiotics and anti-secretory agents. A standard triple therapy consisting of two antibiotics and a proton-pump inhibitor proposed as the first-line regimen. Bismuth-containing quadruple treatment, sequential treatment or a non-bismuth quadruple treatment (concomitant) are also an alternative therapy. Levofloxacin containing triple treatment are recommended as rescue treatment for infection of H. pylori after defeat of first-line therapy. The rapid acquisition of antibiotic resistance reduces the effectiveness of any regimens involving these remedies. Therefore, adding probiotic to the medications, developing anti-H. pylori photodynamic or phytomedicine therapy, and achieving a successful H. pylori vaccine may have the promising to present synergistic or additive consequence against H. pylori, because each of them exert different effects.
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24
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Boyanova L, Gergova G, Evstatiev I, Spassova Z, Kandilarov N, Yaneva P, Markovska R, Mitov I. Helicobacter pyloriresistance to six antibiotics by two breakpoint systems and resistance evolution in Bulgaria. Infect Dis (Lond) 2015; 48:56-62. [DOI: 10.3109/23744235.2015.1082035] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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25
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Abstract
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.
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Affiliation(s)
- Anthony O'Connor
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
| | - Javier P Gisbert
- Department of Gastroenterology, Instituto de Investigación Sanitaria Princesa (IIS-IP), Hospital Universitario de la Princesa, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Colm O'Morain
- Department of Gastroenterology, Tallaght Hospital/Trinity College Dublin, Dublin, Ireland
| | - Spiros Ladas
- Department of Medicine & Gastroenterology, Medical School, "Laiko" University General Hospital of Athens, University of Athens, Athens, Greece
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