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Luzko I, P Nyssen O, Moreira L, Gisbert JP. Safety profile of Helicobacter pylori eradication treatments: literature review and updated data of the European Registry on Helicobacter pylori management (Hp-EuReg). Expert Opin Drug Saf 2024; 23:553-564. [PMID: 38557327 DOI: 10.1080/14740338.2024.2338245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 03/28/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Helicobacter pylori (H. pylori), the most prevalent chronic infection globally, is the major cause of relevant diseases such as gastric cancer, leading to high morbidity and mortality worldwide. Several studies have focused on optimize H. pylori eradication treatment through combination therapies and antibiotic resistance. However, the adverse events profile and its impact, as a primary outcome, remains underexplored.The aim of this review was to summarize the available data on the safety of the most common regimens for H. pylori eradication and its impact on the compliance. AREAS COVERED This review encompassed the published evidence from the years 2008 to 2023 regarding both the safety and compliance for most common H. pylori eradication regimens. The main sources for this review comprised MEDLINE, PubMed, and Cochrane electronic databases. Furthermore, it included a safety analysis of unpublished data from the European Registry on H. pylori management (Hp-EuReg). EXPERT OPINION Poor compliance is correlated with significantly lower cure rates, and this is a unique modifiable source of H. pylori treatment failure. Eradication treatments have become complex, involving multiple drugs and dosing intervals. Thus, patient education is crucial; doctors must explain to the patient about potential temporary and most often harmless side effects.
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Affiliation(s)
- Irina Luzko
- Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), University of Barcelona, Barcelona, Spain
| | - Olga P Nyssen
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Leticia Moreira
- Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBERehd), IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), University of Barcelona, Barcelona, Spain
| | - Javier P Gisbert
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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Smith SI, Schulz C, Ugiagbe R, Ndip R, Dieye Y, Leja M, Onyekwere C, Ndububa D, Ajayi A, Jolaiya TF, Jaka H, Setshedi M, Gunturu R, Otegbayo JA, Lahbabi-Amrani N, Arigbabu AO, Kayamba V, Nashidengo PA. Helicobacter pylori Diagnosis and Treatment in Africa: The First Lagos Consensus Statement of the African Helicobacter and Microbiota Study Group. Dig Dis 2024; 42:240-256. [PMID: 38493766 DOI: 10.1159/000537878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/14/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Helicobacter pylori (H. pylori) infection is the most prevalent type of bacterial infection. Current guidelines from different regions of the world neglect specific African conditions and requirements. The African Helicobacter and Microbiota Study Group (AHMSG), founded in 2022, aimed to create an Africa-specific consensus report reflecting Africa-specific issues. SUMMARY Eighteen experts from nine African countries and two European delegates supported by nine African collaborators from eight other countries prepared statements on the most important African issues in four working groups: (1) epidemiology, (2) diagnosis, (3) indications and prevention, and (4) treatment. Limited resources, restricted access to medical systems, and underdeveloped diagnostic facilities differ from those of other regions. The results of the individual working groups were presented for the final consensus voting, which included all board members. KEY MESSAGES There is a need for further studies on H. pylori prevalence in Africa, with diagnosis hinged on specific African situation. Treatment of H. pylori in the African setting should be based on accessibility and reimbursement, while indication and prevention should be defined in specific African countries.
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Affiliation(s)
- Stella I Smith
- Molecular Biology and Biotechnology Department, Nigerian Institute of Medical Research, Lagos, Nigeria
| | - Christian Schulz
- Medical Department II, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany
- DZIF Deutsches Zentrum für Infektionsforschung, Partner Site Munich, Munich, Germany
| | - Rose Ugiagbe
- Department of Medicine, University of Benin Teaching Hospital, Benin, Nigeria
| | - Roland Ndip
- Department of Microbiology and Parasitology, University of Buea, Buea, Cameroon
| | - Yakhya Dieye
- Pole of Microbiology, Institut Pasteur de Dakar, Dakar, Senegal
| | - Marcis Leja
- Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Charles Onyekwere
- Department of Medicine, Lagos State University Teaching Hospital, Ikeja, Nigeria
| | - Dennis Ndububa
- Department of Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria
| | - Abraham Ajayi
- Molecular Biology and Biotechnology Department, Nigerian Institute of Medical Research, Lagos, Nigeria
| | | | - Hyasinta Jaka
- Department of Internal Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Mashiko Setshedi
- Departments of Medicine, Division of Gastroenterology, University of Cape Town, Cape Town, South Africa
| | - Revathi Gunturu
- Department of Pathology, Aga Khan University Hospital, Nairobi, Kenya
| | | | - Naima Lahbabi-Amrani
- Faculty of Medicine and Pharmacy in Rabat, University Mohammed V, Rabat, Morocco
| | | | - Violet Kayamba
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
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Liu L, Nahata MC. Treatment of Helicobacter pylori Infection in Patients with Penicillin Allergy. Antibiotics (Basel) 2023; 12:antibiotics12040737. [PMID: 37107099 PMCID: PMC10135207 DOI: 10.3390/antibiotics12040737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 03/31/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Helicobacter pylori is among the prevalent causes of infections worldwide, and its resistance rate to antibiotics has been rising over time. Amoxicillin is the cornerstone for the treatment regimen. However, the prevalence of penicillin allergy ranges from 4% to 15%. In patients with true allergy, Vonoprazan-Clarithromycin-Metronidazole and bismuth quadruple therapy have demonstrated excellent eradication and high adherence rates. Vonoprazan-based therapy is administered less frequently and may be better tolerated than bismuth quadruple therapy. Therefore, vonoprazan-based therapy may be considered as a first-line therapy if accessible. Bismuth quadruple therapy can be used as the initial therapy when vonoprazan is unavailable. Levofloxacin or sitafloxacin-based regimens achieve a moderately high eradication rate. However, these are associated with potentially serious adverse effects and should only be used when other effective and safer regimens are unavailable. Cephalosporins such as cefuroxime have been used as an alternative to amoxicillin. Microbial susceptibility studies can guide the selection of appropriate antibiotics. PPI-Clarithromycin-Metronidazole fails to achieve a high eradication rate and should be used as a second-line therapy. PPI-Clarithromycin-Rifabutin should not be used because of low eradication rate and frequent adverse reactions. The choice of the most effective antibiotic regimen can enhance clinical outcomes in patients with H. pylori infection and penicillin allergy.
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Affiliation(s)
- Ligang Liu
- Institute of Therapeutic Innovations and Outcomes (ITIO), College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Milap C Nahata
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
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Ji YH, Shi YM, Hei QW, Sun JM, Yang XF, Wu T, Sun DL, Qi YX. Evaluation of guidelines for diagnosis and treatment of Helicobacter pylori infection. Helicobacter 2023; 28:e12937. [PMID: 36408808 DOI: 10.1111/hel.12937] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 10/11/2022] [Accepted: 10/31/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND To systematically evaluate the quality of the guidelines for the diagnosis and treatment of Helicobacter pylori infection and to analyze the differences and reasons for the key recommendations in the guidelines. METHODS Databases and websites were systematically searched to obtain guidelines for the diagnosis and treatment of Helicobacter pylori infection. Four independent reviewers used the Guideline Evaluation Tool (AGREE II) to evaluate the included guidelines. The intraclass correlation coefficient (ICC) and Fleiss' kappa coefficient were used to measure the consistency of evaluation guidelines between guide reviewers. Differences between guidelines and the reasons for the differences were analyzed by comparing the recommendations of different guidelines and the evidence supporting the recommendations. RESULTS A total of 17 guidelines for Helicobacter pylori infection were included in this study. The AGREE II scores of these guidelines were low overall, with 4 of them had a score of over 60%, which indicates that the guidelines are recommended, and 13 of them having a score ranging from 30 to 60%, which indicates that the guidelines are recommended but need to be revised, while no guideline had a score of 30% or less, which indicates that they were not recommended. The analysis of these guidelines found that there were some differences in the main recommendations. Not all guidelines recommend sequential therapy as the recommended therapy. Whether bismuth quadruple therapy should be used as the recommended first-line therapy is unclear. The antibiotic resistance rate is different in different regions. Combined with the local antibiotic sensitivity test, the eradication rate of Helicobacter pylori can be improved. CONCLUSION There are significant differences in the quality of Helicobacter pylori infection guidelines and the key recommendations. Improving the deficiencies of existing guidelines is an effective way to develop high-quality guidelines and make reasonable recommendations for the treatment of Helicobacter pylori infection in the future.
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Affiliation(s)
- Yan-Hong Ji
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University/Second Faculty of Clinical Medicine, Kunming Medical University, Kunming, China
| | - Yan-Mei Shi
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University/Second Faculty of Clinical Medicine, Kunming Medical University, Kunming, China
| | - Qian-Wen Hei
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University/Second Faculty of Clinical Medicine, Kunming Medical University, Kunming, China
| | - Jin-Min Sun
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University/Second Faculty of Clinical Medicine, Kunming Medical University, Kunming, China
| | - Xiao-Feng Yang
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University/Second Faculty of Clinical Medicine, Kunming Medical University, Kunming, China
| | - Tao Wu
- Department of infectious diseases, The First People's Hospital of Kunming, Kunming, China
| | - Da-Li Sun
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University/Second Faculty of Clinical Medicine, Kunming Medical University, Kunming, China
| | - Yu-Xing Qi
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University/Second Faculty of Clinical Medicine, Kunming Medical University, Kunming, China
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A Comparison of Doxycycline and Amoxicillin Containing Quadruple Eradication Therapy for Treating Helicobacter pylori-Infected Duodenal Ulcers: A Multicenter, Opened, Randomized Controlled Trial in China. Pathogens 2022; 11:pathogens11121549. [PMID: 36558883 PMCID: PMC9783029 DOI: 10.3390/pathogens11121549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/28/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Background: Increased antibiotic resistance is one of the major factors contributing to the failure of H. pylori eradication. This study aimed to compare the efficacy and safety of doxycycline and amoxicillin, both critical components for bismuth-based quadruple therapy, for the first-line treatment of H. pylori-infected duodenal ulcers. Methods: An open, randomized case-controlled, multicenter trial was conducted in seven hospitals in China. A total of 184 eligible participants were divided into an IDFB (ilaprazole 5 mg, doxycycline 100 mg, furazolidone 100 mg, and bismuth 220 mg bid) or IAFB (ilaprazole 5 mg, amoxicillin 1000 mg, furazolidone 100 mg, and bismuth 220 mg bid) group for 14 days. Both groups were administrated with ilaprazole 5 mg qd for another 14 days. The main outcome was an H. pylori eradication rate; secondary outcomes were ulcer healing, relief of symptoms, and incidence of adverse effects. Results: The H. pylori eradication rates were 85.9% (95% CI 78.6−93.9) in the IDFB vs. 84.8% (95% CI 77.3−92.3) in the IAFB group in ITT analysis (p > 0.05), and 92.9% (95% CI 87.4−98.5) vs. and 91.8% (95% CI 85.8−97.7) in PP analysis (p > 0.05). The overall ulcer healing rates of IDFB and IAFB were 79.1% and 84.7% (p > 0.05), both effective in relieving symptoms. Only nine participants had adverse reactions in this trial (4/92 in IDFB and 5/92 in IAFB). Conclusion: A bismuth quadruple regimen containing doxycycline or amoxicillin could be an effective and safe treatment for H. pylori eradication, while doxycycline replacement is an alternative for participants with penicillin allergy.
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Multiple Bismuth Quadruple Therapy Containing Tetracyclines Combined with Other Antibiotics and Helicobacter pylori Eradication Therapy. J Clin Med 2022; 11:jcm11237040. [PMID: 36498615 PMCID: PMC9741466 DOI: 10.3390/jcm11237040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/24/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Helicobacter pylori (HP) infection is closely associated with the development of chronic gastritis, peptic ulcer, and gastric cancer. However, the resistance rate of H. pylori strains to antibiotics such as clarithromycin, metronidazole, and levofloxacin has increased significantly, resulting in a significant decrease in the eradication efficacy of commonly used regimens. Tetracycline has received the attention of domestic and foreign scholars because of its low resistance. The purpose of this review is to provide an update on the tetracycline-containing bismuth quadruple eradication therapy for H. pylori infection and review the efficacy and safety of the regimens, hoping to provide guidance for clinical practice.
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Gisbert JP, Alcedo J, Amador J, Bujanda L, Calvet X, Castro-Fernández M, Fernández-Salazar L, Gené E, Lanas Á, Lucendo AJ, Molina-Infante J, Nyssen OP, Pérez-Aisa A, Puig I. V Spanish Consensus Conference on Helicobacter pylori infection treatment. GASTROENTEROLOGIA Y HEPATOLOGIA 2022; 45:392-417. [PMID: 34629204 DOI: 10.1016/j.gastrohep.2021.07.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/30/2021] [Accepted: 07/16/2021] [Indexed: 02/07/2023]
Abstract
Helicobacter pylori infection is very common in the Spanish population and represents the main cause of chronic gastritis, peptic ulcer, and gastric cancer. The last iteration of Spanish consensus guidelines on H. pylori infection was conducted in 2016. Recent changes in therapeutic schemes along with increasing supporting evidence were key for developing the V Spanish Consensus Conference (May 2021). Fourteen experts performed a systematic review of the scientific evidence and developed a series of recommendations that were subjected to an anonymous Delphi process of iterative voting. Scientific evidence and the strength of the recommendation were classified using GRADE guidelines. An eradication therapy, when prescribed empirically, is considered acceptable when it reliably achieves, or preferably surpass, 90% cure rates. Currently, only quadruple therapies (with or without bismuth) and generally lasting 14 days, accomplish this goal in first- and second-line therapies. A non-bismuth quadruple concomitant regimen (proton pump inhibitor, clarithromycin, amoxicillin, and metronidazole) or a quadruple bismuth-based combination (proton pump inhibitor, bismuth, tetracycline, and metronidazole), are recommended as first-line regimens. Rescue therapies after eradication failure and management of H. pylori infection in peptic ulcer disease were also reviewed.
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Affiliation(s)
- Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
| | - Javier Alcedo
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, España
| | - Javier Amador
- Medicina de Familia, Centro de Salud Los Ángeles, Dirección Asistencial Centro, SERMAS, Madrid, España
| | - Luis Bujanda
- Servicio de Aparato Digestivo, Hospital Donostia/Instituto Biodonostia, Universidad del País Vasco UPV/EHU, CIBEREHD, San Sebastián, España
| | - Xavier Calvet
- Servicio de Aparato Digestivo, Hospital Parc Taulí, Universitat Autónoma de Barcelona, CIBEREHD, Sabadell, Barcelona, España
| | | | - Luis Fernández-Salazar
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Valladolid, Gerencia Regional de Salud (SACYL), Universidad de Valladolid, Valladolid, España
| | - Emili Gené
- Servicio de Urgencias, Hospital Parc Taulí Sabadell, CIBEREHD, Universitat Internacional de Catalunya, Barcelona, España
| | - Ángel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Zaragoza, Instituto de Investigación Sanitaria de Aragón (IIS Aragón), CIBEREHD, Zaragoza
| | - Alfredo J Lucendo
- Servicio de Aparato Digestivo, Hospital General de Tomelloso, CIBEREHD, Ciudad Real, España
| | - Javier Molina-Infante
- Servicio de Aparato Digestivo, Hospital Universitario de Cáceres, CIBEREHD, Cáceres, España
| | - Olga P Nyssen
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España
| | - A Pérez-Aisa
- Servicio de Aparato Digestivo, Agencia Sanitaria Costa del Sol, Marbella, Málaga, España
| | - Ignasi Puig
- Servicio de Aparato Digestivo, Althaia Xarxa Assistencial Universitària de Manresa, Universitat de Vic-Universitat Central de Catalunya (UVicUCC), Manresa, Barcelona, España
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Nyssen OP, Vaira D, Tepes B, Kupcinskas L, Bordin D, Pérez-Aisa Á, Gasbarrini A, Castro-Fernández M, Bujanda L, Garre A, Lucendo A, Vologzhanina L, Jurecic NB, Rodrigo-Sáez L, Huguet JM, Voynovan I, Perez-Lasala J, Romero PM, Vujasinovic M, Abdulkhakov R, Barrio J, Fernandez-Salazar L, Mégraud F, O'Morain C, Gisbert JP. Room for Improvement in the Treatment of Helicobacter pylori Infection: Lessons from the European Registry on H. pylori Management (Hp-EuReg). J Clin Gastroenterol 2022; 56:e98-e108. [PMID: 33405435 DOI: 10.1097/mcg.0000000000001482] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Managing Helicobacter pylori infection requires constant decision making, and each decision is open to possible errors. AIM The aim was to evaluate common mistakes in the eradication of H. pylori, based on the "European Registry on Helicobacter pylori management". METHODS European Registry on Helicobacter pylori management is an international multicentre prospective noninterventional registry evaluating the decisions and outcomes of H. pylori management by European gastroenterologists in routine clinical practice. RESULTS Countries recruiting more than 1000 patients were included (26,340 patients). The most common mistakes (percentages) were: (1) To use the standard triple therapy where it is ineffective (46%). (2) To prescribe eradication therapy for only 7 to 10 days (69%). (3) To use a low dose of proton pump inhibitors (48%). (4) In patients allergic to penicillin, to prescribe always a triple therapy with clarithromycin and metronidazole (38%). (5) To repeat certain antibiotics after eradication failure (>15%). (6) Failing to consider the importance of compliance with treatment (2%). (7) Not to check the eradication success (6%). Time-trend analyses showed progressive greater compliance with current clinical guidelines. CONCLUSION The management of H. pylori infection by some European gastroenterologists is heterogeneous, frequently suboptimal and discrepant with current recommendations. Clinical practice is constantly adapting to updated recommendations, although this shift is delayed and slow.
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Affiliation(s)
- Olga P Nyssen
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)
| | - Dino Vaira
- Department of Surgical and Clinical Sciences, University of Bologna, Bologna
| | - Bojan Tepes
- Gastroenterology Unit, AM DC Rogaska, Rogaska Slatina
| | - Limas Kupcinskas
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Dmitry Bordin
- Department of Pancreatobiliary and Upper GI Diseases, Moscow Clinical Scientific Center, and A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow
| | - Ángeles Pérez-Aisa
- Digestive Unit, Agencia Sanitaria Costa del Sol, Marbella, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Málaga
| | - Antonio Gasbarrini
- Gastronterology Area, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | | | - Luis Bujanda
- Department of Gastroenterology, Hospital Donostia/Instituto Biodonostia. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd). Universidad del País Vasco (UPV/EHU), Donostia
| | - Ana Garre
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)
| | | | | | | | - Luis Rodrigo-Sáez
- Gastroenterology Unit, Hospital Universitario Central de Asturias, Oviedo
| | - Jose M Huguet
- Hospital General Universitario de Valencia, Valencia
| | - Irina Voynovan
- Department of Pancreatobiliary and Upper GI Diseases, Moscow Clinical Scientific Center, and A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow
| | | | | | | | | | | | | | - Francis Mégraud
- Laboratoire de Bactériologie, Hôpital Pellegrin, Bordeaux Cedex, France
| | - Colm O'Morain
- Trinity College Dublin, Faculty of Health Sciences, Trinity College Dublin, Dublin/IE, Faculty of Health Sciences, Dublin, Ireland
| | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)
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Helicobacter pylori eradication following first-line treatment failure in Europe: What, how and when chose among different standard regimens? A systematic review. Eur J Gastroenterol Hepatol 2021; 33:e66-e70. [PMID: 33741798 DOI: 10.1097/meg.0000000000002100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cure rate following standard first-line regimens for Helicobacter pylori eradication is decreasing so several patients require two or more treatments. Antibiotic susceptibility-based therapy, advised in current guidelines, is largely impracticable in clinical practice. Some 'standard' regimens (triple therapies based on either levofloxacin or rifabutin, bismuth-based quadruple therapies, sequential, concomitant and hybrid therapies) were empirically used as rescue therapies. We performed a systematic review on recent studies carried out in European countries dealing with these regimens. A total of 24 studies, with 3804 patients, were identified. As second-line therapy, Pylera (89.2%) and sequential therapy (92.5%) achieved significantly higher cure rates as compared to all the other regimens. As third-line therapy, levofloxacin-based therapy (84.1%) and Pylera (83.6%) achieved similarly high cure rates, whereas standard, bismuth-based quadruple therapy (64.1%) achieved the lowest. As a rescue therapy, the success rate was close to 75% following all therapies used, with data on rifabutin-based regimen consolidated in the larger sample size. Overall, levofloxacin-amoxicillin triple therapy achieved higher eradication rates when the 14- rather than 10-day regimen was used (87.1 vs. 72.2%; P = 0.003). Among bismuth-based therapies, Pylera achieved a significantly higher eradication rate than standard quadruple therapy (88 vs. 67%; P < 0.0001). These data suggest that a wise 'therapeutic package' following first-line therapy could be Pylera, levofloxacin- and rifabutin-based therapy, as long as Pylera therapy was not used as a first-line regimen and levofloxacin-based regimen was administered for 14 days.
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Dutta AK, Phull PS. Treatment of Helicobacter pylori infection in the presence of penicillin allergy. World J Gastroenterol 2021; 27:7661-7668. [PMID: 34908805 PMCID: PMC8641050 DOI: 10.3748/wjg.v27.i44.7661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/17/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023] Open
Abstract
Therapy of Helicobacter pylori (H.pylori) requires a combination of antibiotics together with an acid suppressing agent; most treatment regimens include Amoxicillin as one of the antibiotics, which is an important constituent as resistance to it is low. However, allergies to the penicillin group of antibiotics are not uncommon, and treating H.pylori infection in such individuals can be challenging due to the restricted choice of regimens. The aim of this review is to summarise the evidence for therapeutic options in patients with H.pylori infection and penicillin allergy. A literature search was conducted in PubMed for English language publications using the key words ‘Helicobacter’ and ‘treatment’ or ‘therapy‘ and ‘penicillin’ or ‘beta-lactam’ and ‘allergy’ or ‘anaphylaxis’. Eighteen studies were identified that specifically evaluated H.pylori treatment success in penicillin allergic patients. The number of subjects in most of them was low and many were retrospective, uncontrolled, single cohort studies. The most effective option for first-line treatment appears to be Bismuth-based quadruple therapy for 10-14 d. The evidence supports second-line treatment with Levoflaxacin-based triple therapy for 10 d. Patients with persistent H.pylori infection after 2 treatment courses should be considered for testing to confirm penicillin allergy. Further treatment should be guided by the results of H.pylori culture and sensitivity testing.
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Affiliation(s)
- Amit Kumar Dutta
- Department of Gastroenterology, Christian Medical College, Vellore 632004, India
- Department of Digestive Disorders, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, United Kingdom
| | - Perminder Singh Phull
- Department of Digestive Disorders, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, United Kingdom
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Xirouchakis E, Georgopoulos SD. Evaluating treatments with rifabutin and amoxicillin for eradication of Helicobacter pylori infection in adults: a systematic review. Expert Opin Pharmacother 2021; 23:201-210. [PMID: 34595999 DOI: 10.1080/14656566.2021.1982894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Elias Xirouchakis
- Department of Gastroenterology and Hepatology, Athens Medical, Paleo Faliron Hospital, Athens, Greece
| | - Sotirios D Georgopoulos
- Department of Gastroenterology and Hepatology, Athens Medical, Paleo Faliron Hospital, Athens, Greece
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Singh SP, Ahuja V, Ghoshal UC, Makharia G, Dutta U, Zargar SA, Venkataraman J, Dutta AK, Mukhopadhyay AK, Singh A, Thapa BR, Vaiphei K, Sathiyasekaran M, Sahu MK, Rout N, Abraham P, Dalai PC, Rathi P, Sinha SK, Bhatia S, Patra S, Ghoshal U, Poddar U, Mouli VP, Kate V. Management of Helicobacter pylori infection: The Bhubaneswar Consensus Report of the Indian Society of Gastroenterology. Indian J Gastroenterol 2021; 40:420-444. [PMID: 34219211 DOI: 10.1007/s12664-021-01186-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/20/2021] [Indexed: 02/04/2023]
Abstract
The Indian Society of Gastroenterology (ISG) felt the need to organize a consensus on Helicobacter pylori (H. pylori) infection and to update the current management of H. pylori infection; hence, ISG constituted the ISG's Task Force on Helicobacter pylori. The Task Force on H. pylori undertook an exercise to produce consensus statements on H. pylori infection. Twenty-five experts from different parts of India, including gastroenterologists, pathologists, surgeons, epidemiologists, pediatricians, and microbiologists participated in the meeting. The participants were allocated to one of following sections for the meeting: Epidemiology of H. pylori infection in India and H. pylori associated conditions; diagnosis; treatment and retreatment; H. pylori and gastric cancer, and H. pylori prevention/public health. Each group reviewed all published literature on H. pylori infection with special reference to the Indian scenario and prepared appropriate statements on different aspects for voting and consensus development. This consensus, which was produced through a modified Delphi process including two rounds of face-to-face meetings, reflects our current understanding and recommendations for the diagnosis and management of H. pylori infection. These consensus should serve as a reference for not only guiding treatment of H. pylori infection but also to guide future research on the subject.
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Affiliation(s)
- Shivaram Prasad Singh
- Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, 753 007, India.
| | - Vineet Ahuja
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Govind Makharia
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Showkat Ali Zargar
- Department of Gastroenterology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, 190 011, India
| | - Jayanthi Venkataraman
- Department of Hepatology, Sri Ramachandra Medical Centre, No. 1 Ramachandra Nagar, Porur, Chennai, 600 116, India
| | - Amit Kumar Dutta
- Department of Gastrointestinal Sciences, Christian Medical College and Hospital, Vellore, 632 004, India
| | - Asish K Mukhopadhyay
- Division of Bacteriology, National Institute of Cholera and Enteric Diseases, Kolkata, 700 010, India
| | - Ayaskanta Singh
- Department of Gastroenterology, IMS and Sum Hospital, Bhubaneswar, 756 001, India
| | - Babu Ram Thapa
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Superspeciality of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Kim Vaiphei
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160 012, India
| | - Malathi Sathiyasekaran
- Department of Pediatric Gastroenterology, Kanchi Kamakoti Childs Trust Hospital, Chennai, 600 034, India
| | - Manoj K Sahu
- Department of Gastroenterology, IMS and Sum Hospital, Bhubaneswar, 756 001, India
| | - Niranjan Rout
- Department of Pathology, Acharya Harihar Post Graduate Institute of Cancer, Manglabag, Cuttack, 753 007, India
| | - Philip Abraham
- P D Hinduja Hospital and Medical Research Centre, Veer Savarkar Marg, Cadel Road, Mahim, Mumbai, 400 016, India
| | - Prakash Chandra Dalai
- Gastro and Kidney Care Hospital, IRC Village, Nayapalli, Bhubaneswar, 751 015, India
| | - Pravin Rathi
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India
| | - Saroj K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Shobna Bhatia
- Department of Gastroenterology and Hepatobiliary Sciences, Sir HN Reliance Foundation Hospital and Research Centre, Raja Rammohan Roy Road, Prarthana Samaj, Girgaon, Mumbai, 400 004, India
| | - Susama Patra
- Department of Pathology, All India Institute of Medical Sciences, Patrapada, Bhubaneswar, 751 019, India
| | - Ujjala Ghoshal
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | | | - Vikram Kate
- Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605 006, India
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Nyssen OP, Bordin D, Tepes B, Pérez-Aisa Á, Vaira D, Caldas M, Bujanda L, Castro-Fernandez M, Lerang F, Leja M, Rodrigo L, Rokkas T, Kupcinskas L, Pérez-Lasala J, Jonaitis L, Shvets O, Gasbarrini A, Simsek H, Axon ATR, Buzás G, Machado JC, Niv Y, Boyanova L, Goldis A, Lamy V, Tonkic A, Przytulski K, Beglinger C, Venerito M, Bytzer P, Capelle L, Milosavljević T, Milivojevic V, Veijola L, Molina-Infante J, Vologzhanina L, Fadeenko G, Ariño I, Fiorini G, Garre A, Garrido J, F Pérez C, Puig I, Heluwaert F, Megraud F, O'Morain C, Gisbert JP. European Registry on Helicobacter pylori management (Hp-EuReg): patterns and trends in first-line empirical eradication prescription and outcomes of 5 years and 21 533 patients. Gut 2021; 70:40-54. [PMID: 32958544 DOI: 10.1136/gutjnl-2020-321372] [Citation(s) in RCA: 115] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/08/2020] [Accepted: 06/26/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The best approach for Helicobacter pylori management remains unclear. An audit process is essential to ensure clinical practice is aligned with best standards of care. DESIGN International multicentre prospective non-interventional registry starting in 2013 aimed to evaluate the decisions and outcomes in H. pylori management by European gastroenterologists. Patients were registered in an e-CRF by AEG-REDCap. Variables included demographics, previous eradication attempts, prescribed treatment, adverse events and outcomes. Data monitoring was performed to ensure data quality. Time-trend and geographical analyses were performed. RESULTS 30 394 patients from 27 European countries were evaluated and 21 533 (78%) first-line empirical H. pylori treatments were included for analysis. Pretreatment resistance rates were 23% to clarithromycin, 32% to metronidazole and 13% to both. Triple therapy with amoxicillin and clarithromycin was most commonly prescribed (39%), achieving 81.5% modified intention-to-treat eradication rate. Over 90% eradication was obtained only with 10-day bismuth quadruple or 14-day concomitant treatments. Longer treatment duration, higher acid inhibition and compliance were associated with higher eradication rates. Time-trend analysis showed a region-dependent shift in prescriptions including abandoning triple therapies, using higher acid-inhibition and longer treatments, which was associated with an overall effectiveness increase (84%-90%). CONCLUSION Management of H. pylori infection by European gastroenterologists is heterogeneous, suboptimal and discrepant with current recommendations. Only quadruple therapies lasting at least 10 days are able to achieve over 90% eradication rates. European recommendations are being slowly and heterogeneously incorporated into routine clinical practice, which was associated with a corresponding increase in effectiveness.
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Affiliation(s)
- Olga P Nyssen
- Gastroenterolgy Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Dmitry Bordin
- Department of Pancreatic, Biliary and Upper Digestive Tract Disorders, AS Loginov Moscow Clinical Scientific Center, Moscow, Russian Federation.,A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Bojan Tepes
- Gastroenterology, AM DC Rogaska, Rogaska Slatina, Slovenia
| | - Ángeles Pérez-Aisa
- Gastroenterology, Agencia Sanitaria Costa del Sol, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Marbella, Spain
| | - Dino Vaira
- Department of of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| | - Maria Caldas
- Gastroenterolgy Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Luis Bujanda
- Gastroenterology, Hospital Donostia/Instituto Biodonostia, Universidad del País Vasco (UPV/EHU), CIBEREHD, San Sebastian, Spain
| | | | - Frode Lerang
- Gastroenterololgy, Østfold Hospital Trust, Grålum, Norway
| | - Marcis Leja
- Digestive Diseases Centre GASTRO, Institute of Clinical and Preventive Medicine & Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Luís Rodrigo
- Gastroenterology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Limas Kupcinskas
- Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Laimas Jonaitis
- Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Oleg Shvets
- Internal Medicine, National Medical University named after O.O.Bogomolets, Kyiv, Ukraine
| | - Antonio Gasbarrini
- Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Halis Simsek
- Internal Medicine/Gastroenterology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - György Buzás
- Gastroenterology, Ferencváros Health Centre, Budapest, Hungary
| | - Jose Carlos Machado
- i3S - Instituto de Investigação e Inovação em Saúde. Medical Faculty of Porto. Universidade do Porto, Porto, Portugal
| | - Yaron Niv
- Gastroenterology, Rabin Medical Center, Tel Aviv University, Petah Tikva, Israel
| | | | - Adrian Goldis
- Gastroenterology, Timisoara Hospital, Timisoara, Romania
| | - Vincent Lamy
- Gastroenterology, Hepatology & Nutrition, CHU de Charleroi, Charleroi, Belgium
| | - Ante Tonkic
- Gastroenterology, University Hospital of Split, University of Split, Split, Croatia
| | | | | | - Marino Venerito
- Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Peter Bytzer
- Clinical Medicine, Zealand University Hospital, Copenhagen University, Copenhagen, Denmark
| | - Lisette Capelle
- Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, Netherlands
| | - Tomica Milosavljević
- Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vladimir Milivojevic
- Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Lea Veijola
- Internal Medicine, Herttoniemi Hospital, Helsinki, Finland
| | | | | | - Galina Fadeenko
- Gastroenterology, Digestive Ukrainian Academy of Medical Sciences, Kyiv, Ukraine
| | - Ines Ariño
- Gastroenterology, Hospital Clinico Universitario Lozano Blesa, CIBEREHD, Zaragoza, Spain
| | - Giulia Fiorini
- Department of of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| | - Ana Garre
- Gastroenterolgy Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Jesús Garrido
- Departmento de Psicología Social y Metodología, Facultad de Psicología, Universidad Autónoma de Madrid, Madrid, Spain
| | - Cristina F Pérez
- Servicio de Medicina Preventiva, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Ignasi Puig
- Gastroenterology, Althaia Xarxa Assistencial Universitària de Manresa and Universitat de Vic-Universitat Central de Catalunya (UVicUCC), Manresa, Spain
| | | | - Francis Megraud
- Laboratoire de Bactétiologie, Hôpital Pellegrin, Bordeaux, France
| | - Colm O'Morain
- Gastroenterology, Trinity College Dublin, Dublin, Ireland
| | - Javier P Gisbert
- Gastroenterolgy Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBEREHD), Madrid, Spain
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Gisbert JP. Rifabutin for the Treatment of Helicobacter Pylori Infection: A Review. Pathogens 2020; 10:pathogens10010015. [PMID: 33379336 PMCID: PMC7823349 DOI: 10.3390/pathogens10010015] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 12/17/2020] [Accepted: 12/24/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Universidad Autónoma de Madrid (UAM), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), 28006 Madrid, Spain
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15
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European Registry on Helicobacter pylori Management: Effectiveness of First and Second-Line Treatment in Spain. Antibiotics (Basel) 2020; 10:antibiotics10010013. [PMID: 33375717 PMCID: PMC7823881 DOI: 10.3390/antibiotics10010013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/18/2020] [Accepted: 12/21/2020] [Indexed: 01/10/2023] Open
Abstract
The management of Helicobacter pylori infection has to rely on previous local effectiveness due to the geographical variability of antibiotic resistance. The aim of this study was to evaluate the effectiveness of first and second-line H. pylori treatment in Spain, where the empirical prescription is recommended. A multicentre prospective non-interventional registry of the clinical practice of European gastroenterologists concerning H. pylori infection (Hp-EuReg) was developed, including patients from 2013 until June 2019. Effectiveness was evaluated descriptively and through a multivariate analysis concerning age, gender, presence of ulcer, proton-pump inhibitor (PPI) dose, therapy duration and compliance. Overall, 53 Spanish hospitals were included, and 10,267 patients received a first-line therapy. The best results were obtained with the 10-day bismuth single-capsule therapy (95% cure rate by intention-to-treat) and with both the 14-day bismuth-clarithromycin quadruple (PPI-bismuth-clarithromycin-amoxicillin, 91%) and the 14-day non-bismuth quadruple concomitant (PPI-clarithromycin-amoxicillin-metronidazole, 92%) therapies. Second-line therapies were prescribed to 2448 patients, with most-effective therapies being the triple quinolone (PPI-amoxicillin-levofloxacin/moxifloxacin) and the bismuth-levofloxacin quadruple schemes (PPI-bismuth-levofloxacin-amoxicillin) prescribed for 14 days (92%, 89% and 90% effectiveness, respectively), and the bismuth single-capsule (10 days, 88.5%). Compliance, longer duration and higher acid inhibition were associated with higher effectiveness. “Optimized” H. pylori therapies achieve over 90% success in Spain.
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Zhou Y, Ye Z, Lu J, Miao S, Lu X, Sun H, Wu J, Wang Y, Huang Y. Long-term changes in the gut microbiota after 14-day bismuth quadruple therapy in penicillin-allergic children. Helicobacter 2020; 25:e12721. [PMID: 32656891 DOI: 10.1111/hel.12721] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/09/2020] [Accepted: 06/16/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Penicillin-allergic children who are infected with Helicobacter pylori constitute a relatively common subgroup. We aimed to study the short-term and long-term effects of bismuth quadruple therapy on gut microbiota in penicillin-allergic children. METHODS We prospectively recruited treatment-naive children with H pylori infection and H pylori-negative asymptomatic children as healthy controls. Patients received 14-day bismuth quadruple therapy consisting of omeprazole, clarithromycin, metronidazole, and bismuth. Fecal samples were collected at weeks 0, 2, 6, and 52. Alterations in the gut microbiota were analyzed by 16S rRNA gene sequencing. RESULTS Twenty-two subjects (14 gastritis patients, 8 duodenal ulcer patients) and 23 controls participated in this study. At week 2, alpha diversity was reduced in both gastritis (P < .05) and ulcer (except P = .16 with Chao 1 index) patients compared with baseline. Some changes persisted at week 6, and all were restored at week 52. Beta diversity was significantly altered 2 weeks after treatment in the gastritis and duodenal ulcer groups (P = .001, P = .002, respectively) and restored at weeks 6 and 52. The mean relative abundance of Bacteroidetes (P < .001, P = .005, respectively) decreased and that of Proteobacteria increased (P < .001, P = .03, respectively). All alterations recovered at week 6 and 52. In both the gastritis and ulcer groups at week 2, some beneficial bacteria were decreased including Bacteroides (P < .001 and P = .003), Faecalibacterium (P < .001 and P = .02), Phascolarctobacterium (P = .002 and P = .004), Roseburia ( P < .001 and P = .13), Bifidobacterium (P = .08 and P = .04), and Blautia (P < .001 and P = .002). Some detrimental bacteria were increased including Escherichia-Shigella (P < .001 and P = .19), Klebsiella (P < .001, and P = .09), Enterococcus (P < .001 and P = .007), and Streptococcus (P = .002 and P = .004). The changes returned to almost the pre-eradication level 1 year after therapy. CONCLUSION Bismuth quadruple therapy causes short-term dysbiosis of the gut microbiota. Most changes recovered 1-year post-eradication, indicating the long-term safety of H pylori therapy.
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Affiliation(s)
- Ying Zhou
- Department of Gastroenterology, Children's Hospital of Fudan University, Shanghai, China
| | - Ziqing Ye
- Department of Gastroenterology, Children's Hospital of Fudan University, Shanghai, China
| | - Junping Lu
- Department of Gastroenterology, Children's Hospital of Fudan University, Shanghai, China
| | - Shijian Miao
- Department of Gastroenterology, Children's Hospital of Fudan University, Shanghai, China
| | - Xiaolan Lu
- Department of Gastroenterology, Children's Hospital of Fudan University, Shanghai, China
| | - Hua Sun
- Department of Gastroenterology, Children's Hospital of Fudan University, Shanghai, China
| | - Jie Wu
- Department of Gastroenterology, Children's Hospital of Fudan University, Shanghai, China
| | - Yuhuan Wang
- Department of Gastroenterology, Children's Hospital of Fudan University, Shanghai, China
| | - Ying Huang
- Department of Gastroenterology, Children's Hospital of Fudan University, Shanghai, China
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Luo L, Huang Y, Liang X, Ji Y, Yu L, Lu H. Susceptibility-guided therapy for Helicobacter pylori-infected penicillin-allergic patients: A prospective clinical trial of first-line and rescue therapies. Helicobacter 2020; 25:e12699. [PMID: 32428369 DOI: 10.1111/hel.12699] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/03/2020] [Accepted: 04/09/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Helicobacter pylori (H pylori) treatment remains a challenge for penicillin-allergic patients. AIM To evaluate the efficacy and tolerability of susceptibility-guided first-line and rescue treatment in H pylori-infected penicillin-allergic patients. METHODS Consecutive H pylori-infected patients with penicillin allergy received a 14-day triple or quadruple therapy based on susceptibility to clarithromycin, levofloxacin, and metronidazole. All received esomeprazole 20 mg twice a day. Metronidazole-susceptible infections received metronidazole plus clarithromycin or levofloxacin triple therapy if susceptible. Clarithromycin- and levofloxacin-resistant infections received metronidazole plus tetracycline triple therapy. Metronidazole-resistant infections received a bismuth-high-dose metronidazole plus clarithromycin or levofloxacin quadruple therapy. Triple-resistant infections received classical bismuth quadruple therapy with high-dose metronidazole. Antimicrobial susceptibility was assessed using the E test method. RESULTS 112 patients were entered (34.8% men, average 47.1 years). Infections in 83.8% (31/37) of treatment-naive subjects and 12.0% (9/75) (P < .001) receiving rescue treatment were susceptible to at least one of the three tested antibiotics. Overall, susceptibility-guided therapy achieved eradication rates of 92.9% (104/112, 95% CI 88.1%-97.7%) by intent-to-treat analysis and 99% (100/101, 95% CI 97.1%-100%) by per-protocol analysis. All regimens achieved eradication rates greater than 90% (P = .327) in the PP populations. Adverse events were relatively frequent; however, compliance remained high. CONCLUSION Susceptibility-guided therapy proved highly effective for penicillin-allergic patients. When available and proven locally effective, the alternative was empiric classical bismuth quadruple therapy. This trial is registered with ClinicalTrials.gov as NCT03708848.
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Affiliation(s)
- Laisheng Luo
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yu Huang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao Liang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yingjie Ji
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lou Yu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai Institute of Digestive Disease, 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, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Nyssen OP, Pérez-Aisa Á, Tepes B, Rodrigo-Sáez L, Romero PM, Lucendo A, Castro-Fernández M, Phull P, Barrio J, Bujanda L, Ortuño J, Areia M, Brglez Jurecic N, Huguet JM, Alcaide N, Voynovan I, María Botargues Bote J, Modolell I, Pérez Lasala J, Ariño I, Jonaitis L, Dominguez-Cajal M, Buzas G, Lerang F, Perona M, Bordin D, Axon T, Gasbarrini A, Marcos Pinto R, Niv Y, Kupcinskas L, Tonkic A, Leja M, Rokkas T, Boyanova L, Shvets O, Venerito M, Bytzer P, Goldis A, Simsek I, Lamy V, Przytulski K, Kunovský L, Capelle L, Milosavljevic T, Caldas M, Garre A, Mégraud F, O'Morain C, Gisbert JP. Helicobacter pylori first-line and rescue treatments in patients allergic to penicillin: Experience from the European Registry on H pylori management (Hp-EuReg). Helicobacter 2020; 25:e12686. [PMID: 32173974 DOI: 10.1111/hel.12686] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/08/2020] [Accepted: 02/10/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Experience in Helicobacter pylori eradication treatment of patients allergic to penicillin is very scarce. A triple combination with a PPI, clarithromycin (C), and metronidazole (M) is often prescribed as the first option, although more recently the use of a quadruple therapy with PPI, bismuth (B), tetracycline (T), and M has been recommended. AIM To evaluate the efficacy and safety of first-line and rescue treatments in patients allergic to penicillin in the "European Registry of H pylori management" (Hp-EuReg). METHODS A systematic prospective registry of the clinical practice of European gastroenterologists (27 countries, 300 investigators) on the management of H pylori infection. An e-CRF was created on AEG-REDCap. Patients with penicillin allergy were analyzed until June 2019. RESULTS One-thousand eighty-four patients allergic to penicillin were analyzed. The most frequently prescribed first-line treatments were as follows: PPI + C + M (n = 285) and PPI + B + T + M (classic or Pylera® ; n = 250). In first line, the efficacy of PPI + C + M was 69%, while PPI + B + T + M reached 91% (P < .001). In second line, after the failure of PPI + C + M, two rescue options showed similar efficacy: PPI + B + T + M (78%) and PPI + C + levofloxacin (L) (71%) (P > .05). In third line, after the failure of PPI + C + M and PPI + C + L, PPI + B + T + M was successful in 75% of cases. CONCLUSION In patients allergic to penicillin, a triple combination with PPI + C + M should not be generally recommended as a first-line treatment, while a quadruple regimen with PPI + B + T + M seems to be a better option. As a rescue treatment, this quadruple regimen (if not previously prescribed) or a triple regimen with PPI + C + L could be used but achieved suboptimal (<80%) results.
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Affiliation(s)
- Olga P Nyssen
- Gastroenterology Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Investigación Sanitaria Princesa (IIS-IP), Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ángeles Pérez-Aisa
- Digestive Unit, Agencia Sanitaria Costa del Sol, Marbella, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Málaga, Spain
| | - Bojan Tepes
- Gastroenterology Unit, AM DC Rogaska, Rogaska Slatina, Slovenia
| | - Luis Rodrigo-Sáez
- Gastroenterology Unit, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | | | | | | | - Luis Bujanda
- Department of Gastroenterology, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Hospital Donostia/Instituto Biodonostia, Universidad del País Vasco (UPV/EHU), Donosti, Spain
| | - Juan Ortuño
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Miguel Areia
- Portuguese Oncology Institute, Coimbra, Portugal
| | | | | | - Noelia Alcaide
- Hospital Clínico Universitario Valladolid, Valladolid, Spain
| | - Irina Voynovan
- Department of Pancreatobiliary and Upper GI Diseases, Moscow Clinical Scientific Center, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | | | | | | | - Inés Ariño
- Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Laimas Jonaitis
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - György Buzas
- Gastroenterology Unit, Ferencváros Policlinic, Budapest, Hungary
| | - Frode Lerang
- Medical Department, Central Hospital Ostfold, Fredrikstad, Norway
| | | | - Dmitry Bordin
- Department of Pancreatobiliary and Upper GI Diseases, Moscow Clinical Scientific Center, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - Toni Axon
- Gastroenterology Unit, University of Leeds, Leeds, UK
| | - Antonio Gasbarrini
- Gastronterology Area, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Ricardo Marcos Pinto
- Centro Hospitalar do Porto, Institute of Biomedical Sciences Abel Salazar, University of Porto and CINTESIS, University of Porto, Porto, Portugal
| | - Yaron Niv
- Department of Gastroenterology, Rabin Medical Center, Tel Aviv University, Petach Tikva, Israel
| | - Limas Kupcinskas
- Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ante Tonkic
- Department of Gastroenterology, School of Medicine, University Hospital of Split, University of Split, Split, Croatia
| | - Marcis Leja
- Faculty of Medicine, Institute of Clinical and Preventive Medicine, University of Latvia, Riga, Latvia
| | - Theodore Rokkas
- Gastroenterology Unit, Henry Dunant Hospital, Athens, Greece
| | - Lyudmila Boyanova
- Department of Medical Microbiology, Medical University of Sofia, Sofia, Bulgaria
| | - Oleg Shvets
- Internal Diseases Department No. 1, National Medical University named after O.O. Bogomolets, Kyiv, Ukraine
| | - Marino Venerito
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, Magdeburg, Germany
| | - Peter Bytzer
- Department of Medicine, Zealand University Hospital, Copenhagen University, Copenhagen, Denmark
| | - Adrian Goldis
- Gastroenterology Unit, Timisoara Hospital, Timisoara, Romania
| | - Ilkay Simsek
- Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Vincent Lamy
- Department of Gastroenterology, Hepatology & Nutrition, CHU Charleroi, Charleroi, Belgium
| | - Krzysztof Przytulski
- Gastroenterology Unit, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Lumír Kunovský
- Department of Gastroenterology and Internal Medicine and Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Lisette Capelle
- Gastroenterology and Hepatology, Erasmus MC University, Rotterdam, The Netherlands
| | - Tomica Milosavljevic
- Medical Department, Clinical Center of Serbia Clinic for Gastroenterology and Hepatology, University of Belgrade, Belgrade, Serbia
| | - María Caldas
- Gastroenterology Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Investigación Sanitaria Princesa (IIS-IP), Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ana Garre
- Gastroenterology Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Investigación Sanitaria Princesa (IIS-IP), Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Francis Mégraud
- Laboratoire de Bactériologie, Hôpital Pellegrin, Bordeaux Cedex, France
| | - Colm O'Morain
- Faculty of Health Sciences, Trinity College Dublin, Dublin, Ireland
| | - Javier P Gisbert
- Gastroenterology Unit, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Investigación Sanitaria Princesa (IIS-IP), Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, Madrid, Spain
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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] [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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20
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Nguyen CT, Davis KA, Nisly SA, Li J. Treatment ofHelicobacter pyloriin Special Patient Populations. Pharmacotherapy 2019; 39:1012-1022. [DOI: 10.1002/phar.2318] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Cynthia T. Nguyen
- Department of Pharmacy University of Chicago Medicine Chicago Illinois
| | - Kyle A. Davis
- Department of Pharmacy Wake Forest Baptist Medical Center Winston Salem North Carolina
| | - Sarah A. Nisly
- School of Pharmacy Wingate University Wingate North Carolina
| | - Julius Li
- Department of Pharmacy Southeast Louisiana Veteran Health Care System New Orleans Louisiana
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21
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Song Z, Fu W, Zhou L. Cefuroxime, levofloxacin, esomeprazole, and bismuth as first-line therapy for eradicating Helicobacter pylori in patients allergic to penicillin. BMC Gastroenterol 2019; 19:132. [PMID: 31345165 PMCID: PMC6659276 DOI: 10.1186/s12876-019-1056-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 07/21/2019] [Indexed: 02/06/2023] Open
Abstract
Background Eradicating Helicobacter pylori infection is clinically challenging, notably in cases with penicillin allergy. Cephalosporin could be used in lieu of amoxicillin to eradicate Helicobacter pylori. The current work aimed to assess therapeutic efficacy and safety of a cefuroxime-based quadruple regimen in treatment-naïve individuals with penicillin allergy, as well as patient compliance. Methods In the present prospective single-center cohort study, 152 Helicobacter pylori infected individuals with penicillin allergy received eradication therapy with cefuroxime (500 mg twice/day), levofloxacin (500 mg once/day), esomeprazole (20 mg twice/day) and bismuth potassium citrate (220 mg twice/day; 14 days). Safety and compliance were evaluated 1 to 3 days upon eradication. The urea breath test was carried out 8 to 12 weeks upon eradication for efficacy assessment. Results This quadruple antimicrobial regimen eradicated the pathogen at 85.5% (95% confidence interval (CI) 79.6–90.8%), 88.4% (95% CI 83.0–93.2%) and 90.1% (95% CI 85.2–94.4%) in intention-to-treat, modified intention-to-treat and per-protocol analyses, respectively, with resistance rates of 4.6 and 40.0% in the background of cefuroxime and levofloxacin, respectively. Meanwhile, 21.3% of patients had adverse reactions, but none was serious. A total of 95.3% of patients showed good compliance. Poor compliance and cefuroxime resistance were detected by uni- or multivariate analyses as independent factors predicting therapeutic failure. Eradication rates in patients with dual levofloxacin and cefuroxime susceptibility, isolated levofloxacin resistance, isolated cefuroxime resistance and dual resistance were 97.2, 84.0, 50.0, and 0%, respectively (P = 0.002). Conclusions Cefuroxime, levofloxacin, esomeprazole, and bismuth achieved decent efficacy, safety and compliance as first-line antimicrobial regimen in patients with Helicobacter pylori and penicillin allergy.
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Affiliation(s)
- Zhiqiang Song
- Department of Gastroenterology, Peking University Third Hospital, Beijing, 100191, China
| | - Wei Fu
- Department of Gastroenterology, Peking University Third Hospital, Beijing, 100191, China
| | - Liya Zhou
- Department of Gastroenterology, Peking University Third Hospital, Beijing, 100191, China.
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22
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Fallone CA, Moss SF, Malfertheiner P. Reconciliation of Recent Helicobacter pylori Treatment Guidelines in a Time of Increasing Resistance to Antibiotics. Gastroenterology 2019; 157:44-53. [PMID: 30998990 DOI: 10.1053/j.gastro.2019.04.011] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/25/2019] [Accepted: 04/03/2019] [Indexed: 12/13/2022]
Abstract
Increasing resistance to antibiotics worldwide has adverse effects on the effectiveness of standard therapies to eradicate Helicobacter pylori infection. We reviewed guidelines developed by expert groups in Europe, Canada, and the United States for the treatment of H pylori infection. We compared the recommendations of these guidelines, reconciled them, and addressed the increasing resistance of H pylori to antibiotic therapy regimens. The guidelines recommend bismuth quadruple therapy for first-line treatment, replacing clarithromycin-based triple therapy. There is consensus for concomitant 4-drug therapy as an alternative, especially when bismuth is not available. When therapy is unsuccessful, it is likely due to resistance to clarithromycin, levofloxacin, and/or metronidazole; these drugs, if used previously, should be avoided in subsequent eradication attempts. Second-line therapies should be bismuth quadruple therapy or levofloxacin triple therapy, depending on suspected resistance, reserving rifabutin-based triple and high-dose dual amoxicillin proton pump inhibitor therapy for subsequent treatment attempts. The increasing resistance of H pylori to antibiotic therapy necessitates local availability of susceptibility tests for individuals, and establishment of regional and national monitoring programs to develop evidence-based locally relevant eradication strategies. Further studies into the development of more easily accessible methods of resistance testing, such as biomarker analysis of stool samples, are required. Options under investigation include substituting vonoprazan for proton pump inhibitors, adding probiotics, and vaccine development. Narrow-spectrum antibiotics and new therapeutic targets could be identified based on genomic, proteomic, and metabolomic analyses of H pylori.
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Affiliation(s)
- Carlo A Fallone
- Department of Medicine, Division of Gastroenterology, McGill University Health Center, Montreal, Québec, Canada.
| | - Steven F Moss
- Department of Medicine, Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany; Ludwig Maximilian University Clinic, Medical Clinic II, München, Germany
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23
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Lee JW, Kim N, Nam RH, Lee SM, Soo In C, Kim JM, Lee DH. Risk factors of rescue bismuth quadruple therapy failure for Helicobacter pylori eradication. J Gastroenterol Hepatol 2019; 34:666-672. [PMID: 30726563 DOI: 10.1111/jgh.14625] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/13/2019] [Accepted: 01/31/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Failure of bismuth quadruple therapy for Helicobacter pylori eradication is frequently observed. To increase the eradication rate, comprehensive analyses need to be performed regarding risk factors of bismuth quadruple therapy failure based on complete standard culture and antimicrobial susceptibility testing results. METHODS Patients with history of failed first therapy who had H. pylori colonies isolated from culture and successful minimum inhibitory concentration (MIC) test were enrolled. Esomeprazole, bismuth, metronidazole, and tetracycline (quadruple) therapies for 7 or 14 days were given. Eradication rate, treatment compliance, adverse events, and risk factors for the failure of bismuth quadruple therapy were analyzed. RESULTS A total 54 patients were enrolled. Overall eradication rate in the present study was 88.8%. The eradication rate for cases with metronidazole resistance such as MIC 8-16 μg/mL or 16-32 μg/mL was 92.8% (13/14). For cases with high level metronidazole resistance (MIC > 32 μg/mL), the eradication rate was only 60% (6/10). Multivariate analysis regarding compliance, treatment duration, age > 60, three kinds of metronidazole MICs, tetracycline MIC > 4 μg/mL, adverse events and any other parameters, "metronidazole resistance, high level (MIC > 32 μg/mL)" was the only independent risk factor for eradication failure (P = 0.007). CONCLUSION For cases with metronidazole resistance at MIC > 32 μg/mL, rescue therapy other than bismuth-containing quadruple therapy is needed.
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Affiliation(s)
- Jung Won Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Nayoung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine
| | - Ryoung Hee Nam
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sun Min Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Choi Soo In
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Mogg Kim
- Department of Microbiology, Hanyang University School of Medicine, Seoul, South Korea
| | - Dong Ho Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine
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Long X, Chen Q, Yu L, Liang X, Liu W, Lu H. Bismuth improves efficacy of proton-pump inhibitor clarithromycin, metronidazole triple Helicobacter pylori therapy despite a high prevalence of antimicrobial resistance. Helicobacter 2018; 23:e12485. [PMID: 29696736 DOI: 10.1111/hel.12485] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Helicobacter pylori (H. pylori) eradication has become increasingly difficult especially for penicillin allergy patients. AIMS To evaluate the efficacy of adding bismuth or high-dose metronidazole to an H. pylori eradication regimen containing a proton-pump inhibitor, clarithromycin, and metronidazole in patients allergic to penicillin. METHODS Pilot study in which penicillin-allergic, treatment-naive subjects were randomized (1:1) to 14-day esomeprazole (20 mg q12h), clarithromycin (500 mg q12h), and high dose of metronidazole (400 mg q6h) with (BECM group) or without (ECM group) bismuth (600 mg q12h). Eradication was confirmed by 13 C-urea breath test 6 weeks after therapy. Antimicrobial susceptibility was assessed by the agar dilution method. Adverse events were recorded. RESULTS Sixty-six subjects were randomized, four were lost to follow-up and eight violated the protocol. The eradication rates were 63.6% (95% CI: 47.2%-80.0%) for ECM vs 84.8% (95% CI 72.6%-97.1%) (p = .049) for BECM by intention-to-treat, 67.7% (95% CI 51.3%-84.2%) vs 90.3% (95% CI 79.9%-100%) (p = .029) by modified ITT, and 70% (95% CI 53.6%-86.4%) vs 96% (95% CI 88.3%-100%) (P = .033) by per-protocol. Metronidazole, clarithromycin, and dual-resistant rates were 74.2%, 24.2%, and 18.2%, respectively. The cure rates were significantly improved by the addition of bismuth for both clarithromycin-resistant isolates (100% vs 25%, P = .024) and metronidazole-resistant isolates (94.7% vs 63.6%, P = .043). Adverse events were reported by 45.5% of subjects in ECM group and 48.5% in the BECM group (P = .805). CONCLUSIONS This prospective trial demonstrated that while high-dose metronidazole could not completely overcome metronidazole resistance, bismuth was additive and improved the overall cure rates by 21%-26%.
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Affiliation(s)
- Xiaohua Long
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Institute of Digestive Disease, Shanghai Jiao Tong University, Shanghai, China
| | - Qi Chen
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Institute of Digestive Disease, Shanghai Jiao Tong University, Shanghai, China
| | - Lou Yu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Institute of Digestive Disease, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao Liang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Institute of Digestive Disease, Shanghai Jiao Tong University, Shanghai, China
| | - Wenzhong Liu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Institute of Digestive Disease, 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 Institute of Digestive Disease, Shanghai Jiao Tong University, Shanghai, China
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25
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COELHO LGV, MARINHO JR, GENTA R, RIBEIRO LT, PASSOS MDCF, ZATERKA S, ASSUMPÇÃO PP, BARBOSA AJA, BARBUTI R, BRAGA LL, BREYER H, CARVALHAES A, CHINZON D, CURY M, DOMINGUES G, JORGE JL, MAGUILNIK I, MARINHO FP, MORAES-FILHO JPD, PARENTE JML, PAULA-E-SILVA CMD, PEDRAZZOLI-JÚNIOR J, RAMOS AFP, SEIDLER H, SPINELLI JN, ZIR JV. IVTH BRAZILIAN CONSENSUS CONFERENCE ON HELICOBACTER PYLORI INFECTION. ARQUIVOS DE GASTROENTEROLOGIA 2018; 55:97-121. [DOI: 10.1590/s0004-2803.201800000-20] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 02/22/2018] [Indexed: 02/06/2023]
Abstract
ABSTRACT Significant progress has been obtained since the III Brazilian Consensus Conference on H. pylori infection held in 2012, in Bento Gonçalves, Brazil, and justify a fourth meeting to establish updated guidelines on the current management of H. pylori infection. Therefore, the Núcleo Brasileiro para Estudo do Helicobacter pylori e Microbiota (NBEHPM), association linked to Brazilian Federation of Gastroenterology (FBG) held its fourth meeting again in Bento Gonçalves, RS, Brazil, on August 25-27, 2017. Twenty-six delegates, including gastroenterologists, endoscopists, and pathologists from the five regions of Brazil as well as one international guest from the United States, participated in the meeting. The participants were invited based on their knowledge and contribution to the study of H. pylori infection. The meeting sought to review different aspects of treatment for infection; establish a correlation between infection, dyspepsia, intestinal microbiota changes, and other disorders with a special emphasis on gastric cancer; and reassess the epidemiological and diagnostic aspects of H. pylori infection. Participants were allocated into four groups as follows: 1) Epidemiology and Diagnosis, 2) Dyspepsia, intestinal microbiota and other afections, 3) Gastric Cancer, and, 4) Treatment. Before the consensus meeting, participants received a topic to be discussed and prepared a document containing a recent literature review and statements that should be discussed and eventually modified during the face-to-face meeting. All statements were evaluated in two rounds of voting. Initially, each participant discussed the document and statements with his group for possible modifications and voting. Subsequently, during a second voting in a plenary session in the presence of all participants, the statements were voted upon and eventually modified. The participants could vote using five alternatives: 1) strongly agree; 2) partially agree; 3) undecided; 4) disagree; and 5) strongly disagree. The adopted consensus index was that 80% of the participants responded that they strongly or partially agreed with each statement. The recommendations reported are intended to provide the most current and relevant evidences to management of H. pylori infection in adult population in Brazil.
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26
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Pérez-Arellano E, Rodriguez-Garcia MI, Galera Rodenas AB, de la Morena-Madrigal E. Erradicación de la infección por Helicobacter pylori con una nueva terapia cuádruple basada en bismuto en la práctica clínica. GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 41:145-152. [DOI: 10.1016/j.gastrohep.2017.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/03/2017] [Accepted: 08/08/2017] [Indexed: 02/07/2023]
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27
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Mahachai V, Vilaichone RK, Pittayanon R, Rojborwonwitaya J, Leelakusolvong S, Maneerattanaporn M, Chotivitayatarakorn P, Treeprasertsuk S, Kositchaiwat C, Pisespongsa P, Mairiang P, Rani A, Leow A, Mya SM, Lee YC, Vannarath S, Rasachak B, Chakravuth O, Aung MM, Ang TL, Sollano JD, Trong Quach D, Sansak I, Wiwattanachang O, Harnsomburana P, Syam AF, Yamaoka Y, Fock KM, Goh KL, Sugano K, Graham D. Helicobacter pylori management in ASEAN: The Bangkok consensus report. J Gastroenterol Hepatol 2018; 33:37-56. [PMID: 28762251 DOI: 10.1111/jgh.13911] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 07/11/2017] [Accepted: 07/21/2017] [Indexed: 12/13/2022]
Abstract
Helicobacter pylori (H. pylori) infection remains to be the major cause of important upper gastrointestinal diseases such as chronic gastritis, peptic ulcer, gastric adenocarcinoma, and mucosa-associated lymphoid tissue lymphoma. H. pylori management in ASEAN: the Bangkok consensus report gathered key opinion leaders for the region to review and evaluate clinical aspects of H. pylori infection and to develop consensus statements, rationales, and grades of recommendation for the management of H. pylori infection in clinical practice in ASEAN countries. This ASEAN Consensus consisted of 34 international experts from 10 ASEAN countries, Japan, Taiwan, and the United States. The meeting mainly focused on four issues: (i) epidemiology and disease association; (ii) diagnostic tests; (iii) management; and (iv) follow-up after eradication. The final results of each workshop were presented for consensus voting by all participants. Statements, rationale, and recommendations were developed from the available current evidence to help clinicians in the diagnosis and treatment of H. pylori and its clinical diseases.
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Affiliation(s)
- Varocha Mahachai
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,National Gastric Cancer and Gastrointestinal Diseases Research Center, Bangkok, Pathumthani, Thailand
| | - Ratha-Korn Vilaichone
- Department of Medicine, Thammasat University Hospital, Khlong Luang, Pathumthani, Thailand.,National Gastric Cancer and Gastrointestinal Diseases Research Center, Bangkok, Pathumthani, Thailand
| | - Rapat Pittayanon
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,National Gastric Cancer and Gastrointestinal Diseases Research Center, Bangkok, Pathumthani, Thailand
| | | | | | - Monthira Maneerattanaporn
- Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.,National Gastric Cancer and Gastrointestinal Diseases Research Center, Bangkok, Pathumthani, Thailand
| | - Peranart Chotivitayatarakorn
- Department of Medicine, Thammasat University Hospital, Khlong Luang, Pathumthani, Thailand.,National Gastric Cancer and Gastrointestinal Diseases Research Center, Bangkok, Pathumthani, Thailand
| | - Sombat Treeprasertsuk
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Chomsri Kositchaiwat
- Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Pisaln Mairiang
- Department of Medicine, Faculty of Medicine, KhonKaen University, Khon Kaen, Thailand
| | - Aziz Rani
- Department of Gastroenterology and Hepatology, University of Jakarta, Jakarta, Indonesia
| | - Alex Leow
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Swe Mon Mya
- Department of Gastroenterology, Yangon General Hospital, Yangon, Myanmar
| | - Yi-Chia Lee
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | | | | | - Oung Chakravuth
- Calmette Hospital, University of Health Science, Phnom Penh, Cambodia
| | - Moe Myint Aung
- Department of Gastroenterology, Yangon General Hospital, Yangon, Myanmar
| | - Tiing-Leong Ang
- Department of Gastroentrology and Hepatology, Changi General Hospital, Singapore
| | - Jose D Sollano
- Section of Gastroenterology, University of Santo Tomas Hospital, Manila, Philippines
| | - Duc Trong Quach
- Department of Internal Medicine, University of Medicine and Pharmacy, Hochiminh City, Vietnam
| | | | | | | | - Ari Fahrial Syam
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Depok, Indonesia
| | - Yoshio Yamaoka
- Department of Environmental and Preventive Medicine, Faculty of Medicine, Oita University, Yufu, Japan
| | - Kwong-Ming Fock
- Faculty of Medicine, National University of Singapore, Singapore
| | - Khean-Lee Goh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kentaro Sugano
- Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - David Graham
- Department of Medicine, Gastroenterology Section, Baylor College of Medicine and Michael E. DeBakey VA Medicine Center, Houston, Texas, USA
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Sheu B, Wu M, Chiu C, Lo J, Wu D, Liou J, Wu C, Cheng H, Lee Y, Hsu P, Chang C, Chang W, Lin J. Consensus on the clinical management, screening-to-treat, and surveillance of Helicobacter pylori infection to improve gastric cancer control on a nationwide scale. Helicobacter 2017; 22:e12368. [PMID: 28066960 PMCID: PMC5434958 DOI: 10.1111/hel.12368] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 11/12/2016] [Accepted: 11/16/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous international consensus statements provided general policies for the management of Helicobacter pylori infection. However, there are geographic differences in the prevalence and antimicrobial resistance of H. pylori, and in the availability of medications and endoscopy. Thus, nationwide or regional consensus statements are needed to improve control of H. pylori infection and gastric cancer. MATERIALS AND METHODS This consensus statement for management of H. pylori in Taiwan has three major sections: (1) optimal diagnosis and indications; (2) current treatment strategies; and (3) screening-to-treat and surveillance for control of gastric cancer. The literature review emphasized recent data for development of draft statements and determination of levels of evidence. Twenty-five Taiwan experts conducted a consensus conference, by a modified Delphi process, to modify the draft statements. Consensus, defined as an agreement of least 80% of the experts, and recommendation grade were determined by anonymous voting. RESULTS There were 24 consensus statements. Section 1 has seven statements on recommendations for the diagnosis and indications for treatment of H. pylori infection. Section 2 has 10 statements that provide an updated treatment algorithm for first-line, second-line, and third-line regimens. Section 3 has seven statements regarding H. pylori eradication for reducing the risk of gastric cancer, with a cost-benefit analysis. After H. pylori eradication, the consensus highlights the use of endoscopic surveillance and/or chemoprevention to further reduce the burden of gastric cancer. CONCLUSIONS This consensus statement has updated recommendations for improving the clinical management of H. pylori infection in areas such as Taiwan, which have high prevalence of H. pylori infection and gastric cancer.
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Affiliation(s)
- Bor‐Shyang Sheu
- Departments of Institute of Clinical Medicine and Internal MedicineNational Cheng Kung University HospitalCollege of MedicineNational Cheng Kung UniversityTainanTaiwan
- Department of Internal MedicineTainan HospitalMinistry of Health and WelfareTainanTaiwan
| | - Ming‐Shiang Wu
- Department of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
| | - Cheng‐Tang Chiu
- Gastroenterology Endoscopy CenterChang Gung Memorial HospitalLinkoTaiwan
| | - Jing‐Chuan Lo
- Department of Internal MedicineTaipei Veterans General HospitalTaipeiTaiwan
| | - Deng‐Chyang Wu
- Department of Internal MedicinePrivate Kaohsiung Medical University HospitalKaohsiungTaiwan
| | - Jyh‐Ming Liou
- Department of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
| | - Chun‐Ying Wu
- Department of Internal MedicineTaichung Veterans General HospitalTaichungTaiwan
| | - Hsiu‐Chi Cheng
- Departments of Institute of Clinical Medicine and Internal MedicineNational Cheng Kung University HospitalCollege of MedicineNational Cheng Kung UniversityTainanTaiwan
- Department of Internal MedicineTainan HospitalMinistry of Health and WelfareTainanTaiwan
| | - Yi‐Chia Lee
- Department of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
| | - Ping‐I Hsu
- Department of Internal MedicineKaohsiung Veterans General HospitalKaohsiungTaiwan
| | - Chun‐Chao Chang
- Department of Internal MedicinePrivate Taipei Medical University HospitalTaipeiTaiwan
| | - Wei‐Lun Chang
- Departments of Institute of Clinical Medicine and Internal MedicineNational Cheng Kung University HospitalCollege of MedicineNational Cheng Kung UniversityTainanTaiwan
- Department of Internal MedicineTainan HospitalMinistry of Health and WelfareTainanTaiwan
| | - Jaw‐Town Lin
- School of MedicineFu Jen Catholic UniversityNew Taipei CityTaiwan
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Ono S, Kato M, Nakagawa S, Mabe K, Sakamoto N. Vonoprazan improves the efficacy of Helicobacter pylori eradication therapy with a regimen consisting of clarithromycin and metronidazole in patients allergic to penicillin. Helicobacter 2017; 22. [PMID: 28098408 DOI: 10.1111/hel.12374] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although all Helicobacter pylori (H. pylori)-positive patients should receive eradication therapy, the therapy is a challenge for patients allergic to penicillin. There have been a few reports on the efficacy of eradication therapy for such patients. OBJECTIVE To analyze the efficacy of vonoprazan or proton pump inhibitor (PPI)-based 7-day triple therapy in patients allergic to penicillin. MATERIALS AND METHODS A total of 88 consecutive patients allergic to penicillin who received H. pylori eradication therapy were retrospectively analyzed. Thirty-one patients had a history of failed eradication therapy. Four 7-day regimens were prescribed during the study period: clarithromycin-metronidazole-PPI (13 patients), clarithromycin-metronidazole-vonoprazan (14 patients), metronidazole-sitafloxacin-PPI (44 patients) and metronidazole-sitafloxacin-vonoprazan (17 patients). A 13 C-urea breath test was used for confirmation of eradication, and efficacy of eradication was evaluated by "intention-to-treat" analysis and "per-protocol" analysis. RESULTS Intention-to-treat and per-protocol eradication rates were 46.2%/54.6% for patients who received clarithromycin-metronidazole-PPI, 92.9/92.9% for patients who received clarithromycin-metronidazole-vonoprazan, 100/100% for patients who received metronidazole-sitafloxacin-PPI and 88.2/93.8% for patients who received metronidazole-sitafloxacin-vonoprazan. For first eradication, vonoprazan significantly raised the intention-to-treat efficacy of the triple therapy including clarithromycin-metronidazole (vonoprazan: 92.9%, PPI: 46.2%, P=.0128). A 7-day regimen consisting of metronidazole and sitafloxacin was effective for patients allergic to penicillin with or without past failure of eradication. CONCLUSION For first eradication in patients allergic to penicillin, a 7-day triple therapy consisting of clarithromycin, metronidazole and vonoprazan could be a candidate eradication regimen.
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Affiliation(s)
- Shoko Ono
- Division of Endoscopy, Hokkaido University Hospital, Sapporo, Japan
| | - Mototsugu Kato
- Department of Gastroenterology, National Hospital Organization Hakodate Hospital, Hakodate, Japan
| | - Soichi Nakagawa
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Katsuhiro Mabe
- Department of Gastroenterology, National Hospital Organization Hakodate Hospital, Hakodate, Japan
| | - Naoya Sakamoto
- Department of Gastroenterology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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30
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Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol 2017; 112:212-239. [PMID: 28071659 DOI: 10.1038/ajg.2016.563] [Citation(s) in RCA: 891] [Impact Index Per Article: 127.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/07/2016] [Indexed: 02/07/2023]
Abstract
Helicobacter pylori (H. pylori) infection is a common worldwide infection that is an important cause of peptic ulcer disease and gastric cancer. H. pylori may also have a role in uninvestigated and functional dyspepsia, ulcer risk in patients taking low-dose aspirin or starting therapy with a non-steroidal anti-inflammatory medication, unexplained iron deficiency anemia, and idiopathic thrombocytopenic purpura. While choosing a treatment regimen for H. pylori, patients should be asked about previous antibiotic exposure and this information should be incorporated into the decision-making process. For first-line treatment, clarithromycin triple therapy should be confined to patients with no previous history of macrolide exposure who reside in areas where clarithromycin resistance amongst H. pylori isolates is known to be low. Most patients will be better served by first-line treatment with bismuth quadruple therapy or concomitant therapy consisting of a PPI, clarithromycin, amoxicillin, and metronidazole. When first-line therapy fails, a salvage regimen should avoid antibiotics that were previously used. If a patient received a first-line treatment containing clarithromycin, bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options. If a patient received first-line bismuth quadruple therapy, clarithromycin or levofloxacin-containing salvage regimens are the preferred treatment options. Details regarding the drugs, doses and durations of the recommended and suggested first-line and salvage regimens can be found in the guideline.
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Affiliation(s)
- William D Chey
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | | | - Colin W Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Steven F Moss
- Division of Gastroenterology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Mori H, Suzuki H, Matsuzaki J, Masaoka T, Kanai T. Antibiotic resistance and gyrA mutation affect the efficacy of 10-day sitafloxacin-metronidazole-esomeprazole therapy for Helicobacter pylori in penicillin allergic patients. United European Gastroenterol J 2017; 5:796-804. [PMID: 29026593 DOI: 10.1177/2050640616688995] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/20/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND AIM Helicobacter pylori (H. pylori) eradication regimen has not been standardized for patients with penicillin allergy. We investigated the association between the efficacy of a 10-day sitafloxacin, metronidazole, and esomeprazole triple regimen and antibiotic resistance, in patients with penicillin allergy. METHODS Penicillin-allergic patients infected with H. pylori were enrolled between March 2014 and November 2015. The minimum inhibitory concentrations (MICs) of sitafloxacin and metronidazole, and the gyrA mutation status of the H. pylori strains were determined before treatment. The cut-off points for antimicrobial resistance were defined as 8.0 µg/ml for metronidazole and 0.12 µg/ml for sitafloxacin. The patients received the triple therapy (20 mg esomeprazole, bid; 250 mg metronidazole, bid; and 100 mg sitafloxacin, bid) for 10 days. Successful eradication was evaluated using the [13C] urea breath test or the H. pylori stool antigen test. RESULTS Fifty-seven patients were analyzed, and the overall eradication rate was 89.5%. The eradication rate in cases of double antibiotic resistance to metronidazole and sitafloxacin was 40.0%, whereas for other combinations of resistance, this was above 90.0%. Finally, the eradication rate of gyrA mutation-negative strains was 96.2%, whereas for gyrA mutation-positive strains, it was 83.9%. Adverse events were reported in 31.6% of cases, all of which were mild and tolerable. CONCLUSION Ten days of sitafloxacin and metronidazole triple therapy was safe and highly effective in eradicating H. pylori in penicillin-allergic patients. Double resistance to metronidazole and sitafloxacin was an important predicting factor for eradication failure. However, 10 days of the sitafloxacin and metronidazole triple therapy was highly effective if the strain was susceptible to either sitafloxacin or metronidazole.
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Affiliation(s)
- Hideki Mori
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.,Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Hidekazu Suzuki
- Medical Education Center, Keio University School of Medicine, Tokyo, Japan
| | - Juntaro Matsuzaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.,Division of Molecular and Cellular Medicine, National Cancer Center Research Institute, Tokyo, Japan
| | - Tatsuhiro Masaoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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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: 1787] [Impact Index Per Article: 255.3] [Reference Citation Analysis] [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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Gisbert JP, Molina-Infante J. Current treatment of Helicobacter pylori infection. Med Clin (Barc) 2016; 148:20-22. [PMID: 27916266 DOI: 10.1016/j.medcli.2016.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 10/26/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
| | - Javier Molina-Infante
- Servicio de Aparato Digestivo, Hospital San Pedro de Alcántara, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Cáceres, España
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34
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Fallone CA, Chiba N, van Zanten SV, Fischbach L, Gisbert JP, Hunt RH, Jones NL, Render C, Leontiadis GI, Moayyedi P, Marshall JK. The Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults. Gastroenterology 2016; 151:51-69.e14. [PMID: 27102658 DOI: 10.1053/j.gastro.2016.04.006] [Citation(s) in RCA: 572] [Impact Index Per Article: 71.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND & AIMS Helicobacter pylori infection is increasingly difficult to treat. The purpose of these consensus statements is to provide a review of the literature and specific, updated recommendations for eradication therapy in adults. METHODS A systematic literature search identified studies on H pylori treatment. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an online platform, finalized, and voted on by an international working group of specialists chosen by the Canadian Association of Gastroenterology. RESULTS Because of increasing failure of therapy, the consensus group strongly recommends that all H pylori eradication regimens now be given for 14 days. Recommended first-line strategies include concomitant nonbismuth quadruple therapy (proton pump inhibitor [PPI] + amoxicillin + metronidazole + clarithromycin [PAMC]) and traditional bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline [PBMT]). PPI triple therapy (PPI + clarithromycin + either amoxicillin or metronidazole) is restricted to areas with known low clarithromycin resistance or high eradication success with these regimens. Recommended rescue therapies include PBMT and levofloxacin-containing therapy (PPI + amoxicillin + levofloxacin). Rifabutin regimens should be restricted to patients who have failed to respond to at least 3 prior options. CONCLUSIONS Optimal treatment of H pylori infection requires careful attention to local antibiotic resistance and eradication patterns. The quadruple therapies PAMC or PBMT should play a more prominent role in eradication of H pylori infection, and all treatments should be given for 14 days.
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Affiliation(s)
- Carlo A Fallone
- Division of Gastroenterology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada.
| | - Naoki Chiba
- Guelph GI and Surgery Clinic, Guelph, Ontario, Canada; Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
| | | | - Lori Fischbach
- Department of Epidemiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Javier P Gisbert
- Gastroenterology Service, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Richard H Hunt
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada; Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Nicola L Jones
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Departments of Paediatrics and Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Craig Render
- Kelowna General Hospital, Kelowna, British Columbia, Canada
| | - Grigorios I Leontiadis
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada; Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada; Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - John K Marshall
- Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada; Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Gisbert JP, Molina-Infante J, Amador J, Bermejo F, Bujanda L, Calvet X, Castro-Fernández M, Cuadrado-Lavín A, Elizalde JI, Gene E, Gomollón F, Lanas Á, Martín de Argila C, Mearin F, Montoro M, Pérez-Aisa Á, Pérez-Trallero E, McNicholl AG. IV Spanish Consensus Conference on Helicobacter pylori infection treatment. GASTROENTEROLOGIA Y HEPATOLOGIA 2016; 39:697-721. [PMID: 27342080 DOI: 10.1016/j.gastrohep.2016.05.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 05/18/2016] [Accepted: 05/19/2016] [Indexed: 02/06/2023]
Abstract
Helicobacter pylori approximately infect 50% of Spanish population and causes chronic gastritis, peptic ulcer and gastric cancer. Until now, three consensus meetings on H.pylori infection had been performed in Spain (the last in 2012). The changes in the treatment schemes, and the increasing available evidence, have justified organizing the IVSpanish Consensus Conference (March 2016), focused on the treatment of this infection. Nineteen experts participated, who performed a systematic review of the scientific evidence and developed a series of recommendation that were subjected to an anonymous Delphi process of iterative voting. Scientific evidence and the strength of the recommendation were classified using GRADE guidelines. As starting point, this consensus increased the minimum acceptable efficacy of recommended treatments that should reach, or preferably surpass, the 90% cure rate when prescribed empirically. Therefore, only quadruple therapies (with or without bismuth), and generally lasting 14 days, are recommended both for first and second line treatments. Non-bismuth quadruple concomitant regimen, including a proton pump inhibitor, clarithromycin, amoxicillin and metronidazole, is recommended as first line. In the present consensus, other first line alternatives and rescue treatments are also reviewed and recommended.
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Affiliation(s)
- Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
| | | | - Javier Amador
- Medicina de Familia, Centro de Salud Los Ángeles, Madrid, España
| | - Fernando Bermejo
- Servicio de Aparato Digestivo, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | - Luis Bujanda
- Servicio de Digestivo, Hospital Donostia/Instituto Biodonostia, Universidad del País Vasco UPV/EHU, CIBEREHD, San Sebastián, España
| | - Xavier Calvet
- Servicio de Aparato Digestivo, Hospital Parc Taulí, Universitat Autónoma de Barcelona, CIBEREHD, Sabadell, Barcelona, España
| | | | | | - J Ignasi Elizalde
- Servicio de Aparato Digestivo, Hospital Clínic, CIBEREHD, Barcelona, España
| | - Emili Gene
- Servicio de Urgencias, Hospital Parc Taulí Sabadell, CIBEREHD, Universitat Internacional de Catalunya, Sabadell, Barcelona, España
| | - Fernando Gomollón
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, España
| | - Ángel Lanas
- Servicio de Aparato Digestivo, Hospital Clínico Universitario de Zaragoza, IIS Aragón, CIBEREHD, Zaragoza, España
| | - Carlos Martín de Argila
- Servicio de Aparato Digestivo, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, España
| | - Fermín Mearin
- Servicio de Aparato Digestivo, Centro Médico Teknon, Barcelona, España
| | - Miguel Montoro
- Servicio de Aparato Digestivo, Hospital San Jorge, Huesca, España
| | - Ángeles Pérez-Aisa
- Servicio de Aparato Digestivo, Agencia Sanitaria Costa del Sol, Marbella, Málaga, España
| | - Emilio Pérez-Trallero
- Servicio de Microbiología, Hospital Donostia/Instituto Biodonostia, Universidad del País Vasco UPV/EHU, CIBEREHD, San Sebastián, España
| | - Adrián G McNicholl
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España
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Agréus L, Talley NJ, Jones M. Value of the "Test & Treat" Strategy for Uninvestigated Dyspepsia at Low Prevalence Rates of Helicobacter pylori in the Population. Helicobacter 2016; 21:186-91. [PMID: 26347458 DOI: 10.1111/hel.12267] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIM In populations with a low prevalence rate of Helicobacter pylori (H. pylori) infection from Western countries, guidelines for the management of uninvestigated dyspepsia generally recommend that the "test and treat" strategy should be avoided in favor of empiric proton-pump inhibitor therapy in younger patients (on average < 50 years of age) without alarm symptoms and signs. The prevalence of H. pylori infection has fallen from about 30% to about 10% in Sweden and other countries. We aimed to explore whether the rationale for test and treat is relevant in contemporary clinical practice. MATERIALS AND METHODS In settings with an infection rate in the adult population of 30% and 10%, we modeled the positive and negative predictive values for indirect (nonendoscopy) tests on current H. pylori infection with a presumed sensitivity and specificity of 95%. We then calculated the difference in false-negative and false-positive test outcome, and eradication prescription rates in the two scenarios. RESULTS While the positive predictive value for the test decreased from 0.89 to 0.68 when the prevalence of H. pylori fell from 30% to 10%, there were only 1% more false-negative tests and 1% less false-positive tests. The eradication prescription rate would decrease by 18% with a 10% prevalence rate. CONCLUSION The recommendation to stop applying "test and treat" at lower prevalence rates of H. pylori should be reconsidered. The test and treat strategy is the preferred approach for most patients who present with dyspepsia.
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Affiliation(s)
- Lars Agréus
- Division of Family Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle, NSW, Australia
| | - Michael Jones
- Department of Psychology, Macquarie University, Sydney, NSW, Australia
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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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