The eradication of Helicobacter pylori is affected by body mass index (BMI)

Relationship between obesity severity and Helicobacter pylori eradication in patients undergoing bariatric and metabolic surgery: A post hoc analysis

BACKGROUND

The global prevalence of obesity is increasing and represents a major public health challenge. However, there is a paucity of data regarding Helicobacter pylori (H pylori) eradication in people with obesity. The aim of the study is to examine the influence of obesity degree on H. pylori eradication in patients undergoing bariatric and metabolic surgery.

METHODS

A post hoc analysis was conducted in a cohort of 204 adults patients (129 individuals diagnosed with obesity, 75 normal weight) H. pylori positive, included in two multicenter, prospective studies. Patients underwent a 14-day quadruple concomitant treatment, and H. pylori eradication was assessed using the 13C-urea breath test. The cohort was stratified according to body mass index (BMI), and statistical analyses were performed using chi-squared test, Kruskal-Wallis test, and logistic regression.

RESULTS

Eradication rates were significantly lower in patients with obesity compared with normal weight individuals (68.2% vs. 88.0%, OR 0.29, 95% CI 0.13-0.63, p < 0.01). Furthermore, within the population diagnosed with obesity, the degree of obesity correlated with decreased eradication rates, with class 3 (BMI 40.0-49.9) and class 4 (BMI ≥ 50.0) obesity showing the lowest rates (67% and 51%, with an OR 0.28 and 0.15 respectively, p < 0.01).

CONCLUSIONS

Our results indicate that obesity may influence H. pylori eradication, especially among severe obesity patients undergoing bariatric surgery, which could have implications for the development of ulcers and gastritis as well as the risk of gastric cancer. Tailored eradication strategies may be necessary to improve treatment efficacy in this population.

Unveiling the Antibacterial Properties of Statins: An In Vitro Study on Helicobacter pylori

Background

Helicobacter pylori (H. pylori), a widespread bacterial pathogen, is associated with various gastrointestinal diseases, including gastric cancer. Statins, widely prescribed cholesterol-lowering agents, have demonstrated pleiotropic effects, including potential antimicrobial properties. This in vitro study investigated the direct antibacterial effects of three clinically approved statins, simvastatin, atorvastatin, and rosuvastatin, against H. pylori isolates.

Methods

H. pylori strains were isolated from gastric biopsies of dyspeptic patients and identified by microbiological techniques. The minimum inhibitory concentrations (MICs) of statins were determined using the agar dilution method, and their antimicrobial activity was evaluated by the disc diffusion method using different concentrations of simvastatin, atorvastatin, rosuvastatin, tetracycline, and amoxicillin. Scanning electron microscopy (SEM) was employed to examine the morphology of H. pylori cells.

Results

The minimum inhibitory concentration (MIC) values (μg/mL) of atorvastatin, rosuvastatin, simvastatin, tetracycline, and amoxicillin against H. pylori were 240 ± 20, 450 ± 20, 460 ± 15, 155 ± 30, and 140 ± 20, respectively. In the disc diffusion assay, atorvastatin and rosuvastatin produced significantly larger inhibition zones compared to simvastatin at all concentrations tested (p < 0.05). The inhibition zone diameters (mm) increased with higher statin concentrations, ranging from 9 ± 1.4 to 13 ± 1.4 for atorvastatin, 8 ± 0.9 to 11 ± 0.6 for rosuvastatin, and 5 ± 1.3 to 6 ± 1.4 for simvastatin at the highest tested concentration (1200 μg/ml). SEM analysis revealed the characteristic spiral morphology of H. pylori cells.

Conclusion

Statins demonstrated varying degrees of antibacterial activity against H. pylori isolates, with atorvastatin exhibiting the highest potency. While the observed effects were lower than those of conventional antibiotics, these findings suggest the potential of statins as adjunctive agents or alternative therapeutic options, warranting further investigation through in vivo studies and clinical trials.

Prevalence of Helicobacter pylori Infection and Efficacy of Bismuth Quadruple and Levofloxacin Triple Eradication Therapies: A Retrospective Analysis

Helicobacter pylori (H. pylori) infection is a widespread global health issue and a primary cause of diseases like gastritis, gastroduodenal ulcers, and gastric cancer. This study examines the prevalence of H. pylori infection in patients undergoing upper endoscopy and assesses the efficacy of bismuth quadruple therapy (BQT) and levofloxacin triple therapy. A retrospective analysis of 507 gastroscopies was conducted, with indications including epigastric pain, heartburn, postprandial fullness, early satiation, and regurgitation. Rapid urease tests were performed, and endoscopic findings documented. Two treatment regimens were used: BQT as the first-line therapy and levofloxacin triple therapy as the second-line. Of the 507 patients, 68.8% were infected with H. pylori. Gastric ulcer patients had significantly higher H. pylori prevalence compared to those with small polyps, Barrett's esophagus, or normal endoscopy. Among the 310 patients who participated in follow-up interviews, 11.9% did not initiate therapy and 5.1% discontinued due to intolerance. The overall eradication rate was 88.6%, with BQT showing a higher eradication rate (89.4%) compared to levofloxacin triple therapy (83.8%). The study highlights the high prevalence of H. pylori among patients with gastrointestinal symptoms and the effectiveness of BQT as a first-line treatment.

Obesity, abdominal obesity, metabolic obesity phenotypes, and Helicobacter pylori infection: results from NHANES 1999-2000

BACKGROUND

Recent studies on the association between Helicobacter pylori (H. pylori) infection and obesity have reported conflicting results. Therefore, the purpose of our study was to investigate the association of obesity, abdominal obesity, and metabolic obesity phenotypes with H. pylori infection.

METHODS

A cross-sectional study of 1568 participants aged 20 to 85 was conducted using the National Health and Nutrition Examination Survey (NHANES) cycle 1999-2000. Logistic regression models were employed to evaluate the association of general obesity as defined by body mass index (BMI), abdominal obesity as defined by waist circumference (WC) and waist-height ratio (WHtR), and metabolic obesity phenotypes with H. pylori seropositivity. Subgroup analyses stratified by age were conducted to explore age-specific differences in this association.

RESULTS

After grouping individuals according to their WHtR, the prevalence rate of WHtR ≥ 0.5 in H. pylori-seropositive participants was significantly higher than that in H. pylori-seronegative participants (79.75 vs. 68.39, P < 0.001). The prevalence of H. pylori seropositivity in non-abdominal obesity and abdominal obesity defined by WHtR was 24.97% and 31.80%, respectively (P < 0.001). In the subgroup analysis, the adjusted association between abdominal obesity, as defined by the WHtR, and H. pylori seropositivity was significant in subjects aged < 50 years (OR = 2.23; 95% CI, 1.24-4.01; P = 0.01) but not in subjects aged ≥ 50 years (OR = 0.84; 95% CI, 0.35-1.99; P = 0.66). Subjects older than 50 years old had an OR (95% CI) for metabolically healthy obesity of 0.04 (0.01-0.35) compared with the control group. H. pylori seropositivity was consistently not associated with obesity as defined by BMI.

CONCLUSIONS

Abdominal obesity, as defined by the WHtR, was associated with H. pylori infection in subjects aged ≤ 50 years.

Evaluation and implementation of optimized antimicrobial dosing strategies in obese and underweight patients

PURPOSE

We aimed to develop and implement dosing recommendations for antimicrobials in obese and underweight patients within an academic hospital, and assess their impact on antibiotic prescribing.

METHODS

A multi-step approach project was performed. First, obese and underweight patient prevalence and antimicrobial prescription frequency was determined in a point prevalence study. Second and third, a literature review and e-survey provided dosing evidence. Fourth, a consensus meeting was organized to formulate dosing recommendations. Fifth, these were implemented in our clinical validation service as six clinical rules continuously screening patients' records for potentially inappropriate prescriptions (PIPs). Uptake was evaluated by documenting the number of advices and acceptance rate. Last, an interrupted time series analysis (ITS) compared pre- and post-implementation periods to measure the impact of the intervention on residual PIPs/day. A residual PIP was defined as a PIP which persisted up to 48 h.

RESULTS

First, 41% of 15.896 hospitalized patients received antimicrobials over 20 days; of which 12% were obese and 9% underweight. Antibiotics were predominantly prescribed according to standard dosing regimens, adjusted to renal function. Next, six dosing recommendations, derived from literature, survey, and consensus, were implemented. In the fifth step, during an 18-week period, 219 advices were given, with 86% acceptance rate. Last, in the ITS analysis, at preintervention, a median of 75% residual PIPs/day existed, reduced to 0% postintervention. Use of clinical rules resulted in a significant immediate 84% relative reduction in residual PIPs (95% CI 0.55-0.94).

CONCLUSION

After conducting a literature review, e-survey, and seeking consensus from a panel of experts, dosing recommendations for antimicrobial treatment in both obese and underweight patients were developed. These recommendations have been successfully implemented into clinical practice, addressing the specific needs of these patient populations.

Comparison of Helicobacter pylori eradication rates between 7 and 14 days of tailored therapy according to clarithromycin resistance test: A randomized, multicenter, non-inferiority study

BACKGROUND

Recently, a simple tailored therapy based on clarithromycin resistance has been implemented as Helicobacter pylori (H. pylori) eradication therapy. Nonetheless, despite the tailored therapy and frequent adverse events, studies on treatment period are lacking. This study aimed to compare the H. pylori eradication rates of 7-day and 14-day tailored therapy regimens according to clarithromycin resistance.

MATERIALS AND METHODS

This multicenter, prospective, randomized, noninferiority trial enrolled H. pylori-positive patients who were randomly assigned to 7-day and 14-day regimen groups, depending on the presence or absence of clarithromycin resistance by 23S rRNA gene point mutations. Standard triple therapy (STT) (20 mg rabeprazole, 1 g amoxicillin, and 500 mg clarithromycin twice daily) or bismuth quadruple therapy (BQT) (20 mg rabeprazole twice daily, 500 mg metronidazole thrice daily, 120 mg bismuth four times daily, and 500 mg tetracycline four times daily) was assigned by clarithromycin resistance. Eradication rates and adverse events were evaluated.

RESULTS

A total of 314 and 278 patients were included in the intention-to-treat (ITT) and per-protocol (PP) analyses, respectively; however, 31 patients were lost to follow-up, whereas five patients violated the protocol. Both the 7-day and 14-day regimens showed similar eradication rates in the ITT (7-day vs. 14-day: 78.3% vs. 78.3%, p > 0.99) and PP (87.9% vs. 89.1%, p = 0.851) analyses. Non-inferiority was confirmed (p < 0.025). A subgroup analysis according to clarithromycin resistance (clarithromycin resistance rate: 28.7%) revealed no significant difference in eradication rates between the 7-day and 14-day STT (90.0% vs. 90.1%, p > 0.99) and BQT (82.5% vs. 86.5%, p = 0.757). Furthermore, adverse events did not significantly differ between the two groups.

CONCLUSIONS

The 7-day triple and quadruple therapy according to clarithromycin resistance showed similar eradication rates, as compared to the 14-day therapy.

Dual burden of infectious and chronic disease in low-resource U.S. communities: examining relationships between infection, adiposity, and inflammation

BACKGROUND

Rising global obesity rates are linked with inflammation and associated morbidities. These negative outcomes are generally more common in low-resource communities within high-income countries; however, it is unclear how frequent infectious disease exposures in these settings may influence the relationship between adiposity and inflammation.

AIM

We test associations between adiposity measures and distinct forms of inflammation among adults (n = 80) living in low-resource U.S. communities experiencing high levels of obesity and pathogen exposure.

SUBJECTS AND METHODS

Adiposity measures included BMI and percent body fat. Inflammation measures included systemic inflammation (C-reactive protein [CRP]) and localised intestinal inflammation (faecal calprotectin [FC]). The relationship between a condition characterised by elevated inflammation (Helicobacter pylori infection) and adiposity was also considered.

RESULTS

Adiposity was not significantly related to FC concentration. However, both adiposity measures were positively related with odds of CRP elevation and H. pylori infection was associated with significantly lower adiposity measures (all p < 0.05).

CONCLUSION

For this disadvantaged U.S. sample, the association between adiposity and inflammation varies by the systemic/localised nature of inflammation and the likely underlying cause of inflammation. Defining these associations will improve understanding of how rising obesity rates shape long-term health inequities, with implications for more effective intervention design.

The Associations between Helicobacter Pylori immunoglobulin G seropositivity and body mass index in adults

OBJECTIVES

Inconsistent evidence currently exists regarding the associations between Helicobacter Pylori (H. pylori) infection and body mass index (BMI). The goal of the current study was to examine independent associations of H. pylori immunoglobulin G (IgG) seropositivity and BMI in a U.S.-based population sample.

METHODS

The US National Health and Nutrition Examination Survey (NHANES) with 2,576 subjects from 1999 to 2000 were analyzed. Using multivariate logistic regression models, associations between H. pylori IgG seropositivity and BMI were calculated after potential confounders were taken into account. Subgroup analyses were conducted furtherly stratified by sex, age, and race.

RESULTS

H. pylori IgG seropositivity was not associated with BMI in the general population (OR = 0.998; 95% CI = 0.977-1.019; P = 0.842). In the subgroup analyses stratified by race, a negative correction was found between the H. pylori IgG seropositivity and BMI among other races (OR = 0.873; 95% CI = 0.795-0.959; P = 0.004) except non-Hispanic white (OR = 1.006, 95% CI 0.966 to 1.048, P = 0.762), non-Hispanic black (OR = 1.021, 95% CI 0.979 to 1.065, P = 0.335), and Mexican American (OR = 1.010, 95% CI 0.966 to 1.055, P = 0.665).

CONCLUSIONS

In the general population, H. pylori IgG seropositivity is not associated with increased BMI, which provides a new perspective on obesity management.

DO HELICOBACTER PYLORI INFECTION AND ERADICATION THERAPY STATUS INFLUENCE WEIGHT LOSS OUTCOMES AND ENDOSCOPIC FINDINGS AFTER ROUX-EN-Y GASTRIC BYPASS?A HISTORICAL COHORT STUDY

BACKGROUND

Currently, there is conflicting evidence linking Helicobacter pylori (HP) infection with weight loss and endoscopic findings after Roux-en-Y gastric bypass (RYGB).

OBJECTIVE

To identify correlations between HP infection and its eradication with weight loss and endoscopic findings after RYGB.

METHODS

This is an observational retrospective cohort study based on a prospectively collected database of individuals who underwent RYGB from 2018-2019 at a tertiary university hospital. HP infection and the HP eradication therapy outcomes were correlated with post-operative weight loss and endoscopic findings. Individuals were classified according to the status of HP infection into four groups: no infection; successful eradication; refractory infection; and new-onset infection.

RESULTS

Of 65 individuals, 87% were female and the mean age was 39±11.2 years. Body mass index significantly decreased from 36.2±3.6 to 26.7±3.3 kg/m2 one year after RYGB (P<0.0001). The percentage of total weight loss (%TWL) was 25.9±7.2% and the percentage of excess weight loss was 89.4±31.7%. HP infection prevalence decreased from 55.4% to 27.7% (p=0.001); 33.8% never had HP infection, 38.5% were successfully treated, 16.9% had refractory infection and 10.8 % had new-onset HP infection. %TWL was 27.3±7.5% in individuals who never had HP, 25.4±8.1% in the successfully treated, 25.7±5.2% in those with refractory infection, and 23.4±6.4% in the new-onset HP infection group; there were no significant differences among the four groups (P=0.6). Pre-operative HP infection significantly associated with gastritis (P=0.048). New-onset HP infections significantly associated with a lower frequency of jejunal erosions after surgery (P=0.048).

CONCLUSION

No effects of the HP infection on weight loss were identified in individuals undergoing RYGB. A higher prevalence of gastritis was observed in individuals with HP infection before RYGB. New-onset HP infection after RYGB was a protective factor for jejunal erosions.

Is There a Relationship Between Helicobacter Pylori and GERD Before Laparoscopic Sleeve Gastrectomy?

AIM

The aim of this study is to determine the prevalence of Helicobacter pylori (HP) in patients before laparoscopic sleeve gastrectomy (LSG) and to reveal whether HP is associated with gastroesophageal reflux disease (GERD) before LSG.

METHODS

The study included 435 patients who underwent primary LSG between April 2018 and September 2021. All patients underwent preoperative endoscopy. All patients were investigated for the presence of HP. No treatment for HP eradication was given to any of the patients. Patients were divided into 2 groups HP (+) and HP(-), and compared for GERD, complications, and weight loss before and after LSG.

RESULTS

The mean age of the patients was 38.3±11 years (56.1% female), and the mean BMI was 44.2±7.1 kg/m 2 . Symptomatic GERD was found in 102 (23.4%) patients. Endoscopy showed hiatal hernia in 42 (9.7%) patients, and these patients also underwent hiatal hernia repair in the same session. HP was (+) in 125 (28.7%) patients. HP (+) patients were assigned to Group A, while HP (-) patients were assigned to Group B. In the preoperative period, the rate of symptomatic GERD was 22.4% (n=28/125) in Group A and 23.9% (n=74/310) in Group B ( P =0.74). The mean follow-up period was 17±5.7 (range, 12 to 28) months. The mean BMI decreased to 28.3±4.9 kg/m 2 at 12 months after LSG. Given the association between HP and GERD after LSG, it was 25.6% (n=32/125) in Group A and 20% (n=62/310) in Group B ( P =0.2). In addition, there was no difference between the 2 groups in terms of weight loss.

CONCLUSION

This study showed no difference between patients with or without HP infection in terms of GERD before LSG.

Detection and Treatment of Helicobacter pylori: Problems and Advances

Helicobacter pylori (H. pylori) infection is chronic and etiologically linked to gastric cancer (GC) derived from gastric epithelium. The potential mechanism is complex, covering chronic inflammation, epithelial senescence, NF-κB activation, the cytotoxin-associated gene A protein translocation, and related abnormal signaling pathways. In clinical practice, the test-and-treat strategy, endoscopy-based strategy, and (family-based) screen-and-treat strategy are recommended to detect H. pylori and prevent GC. It has been demonstrated that the decreasing annual incidence of GC is largely attributable to the management of H. pylori. This study reviews the current clinical practice of H. pylori on the detection and eradication, alternative treatment strategies, and related problems and advances, and hopes to contribute to the better clinical management of H. pylori.

Helicobacter pylori-Related Extraintestinal Manifestations—Myth or Reality

It is well documented that Helicobacter pylori (H. pylori) can cause both gastrointestinal and extraintestinal manifestations. The latter one represents a major burden in terms of diagnosis and treatment. H. pylori-associated systemic subclinical inflammation is mostly responsible for the development of extraintestinal manifestations, and its early eradication might result in preventing all adverse events related to their occurrence. Thus, it was suggested that H. pylori might be associated with iron deficiency anemia, thrombocytopenia (immune thrombocytopenic purpura), Schonlein Henoch purpura, failure to thrive, vitamin B12 deficiency, diabetes mellitus, body mass index, cardiovascular diseases, as well as certain neurological conditions. Nevertheless, studies showed both pros and cons in terms of the role of H. pylori in the development of previously mentioned clinical entity underlining the crucial need for further studies on these topics. Although most of these extraintestinal manifestations occur during adulthood, we must not forget that H. pylori infection is acquired mainly during childhood, and thus its early diagnosis and eradication might represent the cornerstone in the prevention of H. pylori-induced inflammatory status and consequently of all related extraintestinal conditions.

Rabeprazole plus amoxicillin dual therapy is equally effective to bismuth-containing quadruple therapy for Helicobacter pylori eradication in central China: A single-center, prospective, open-label, randomized-controlled trial

BACKGROUND

Antibiotic resistance emerges as a major issue for Helicobacter pylori (H. pylori) treatment. High-dose dual therapy has recently shown encouraging results in H. pylori eradication, but it has yet to be validated in this H. pylori highly infected area; it is also not known if this concept can be extended to antibiotics other than amoxicillin, and factors that affect the eradication. We investigate if rabeprazole plus amoxicillin or furazolidone regimens could be a first-line therapy for H. pylori eradication, and factors that affect the curing rate.

METHODS

This is a single-center, prospective, open-label, randomized-controlled trial. Naive patients (n=292) were randomly treated with bismuth-containing quadruple therapy (BQT), rabeprazole plus amoxicillin (RADT), or furazolidone (RFDT) groups. RADT and FADT use three times daily regimens. H. pylori diagnosis and eradication were determined and confirmed by ¹³ C-urea breath test.

RESULTS

In per-protocol (PP) analysis, H. pylori eradication rate was 91.2% in BQT group, 89.6% in RADT, and 51.0% in RFDT group. In intention-to-treat (ITT) analysis, infection was eradicated in 86.7% of patients in BQT group, 85.8% in RADT, and 48.1% in RFDT groups, respectively. Noninferiority was confirmed between BQT and RADT groups. The incidence of side effects in BQT group was significantly higher than that in RADT group. Successful eradication was associated with lower body surface area (BSA) and low body mass index (BMI) in BQT group. Smoking and high BSA index reduced H. pylori eradication rate in RADT group.

CONCLUSIONS

Rabeprazole-amoxicillin dual therapy is equally effective to the bismuth-containing quadruple therapy for H. pylori eradication with fewer side effects and saves use of one antibiotic per each treatment. Successful eradication is also associated with low BSA and non-smoking condition, which deserves future stratified analysis for refinement and optimization.

Macrolide Treatment Failure due to Drug–Drug Interactions: Real-World Evidence to Evaluate a Pharmacological Hypothesis

Macrolide antibiotics have received criticism concerning their use and risk of treatment failure. Nevertheless, they are an important class of antibiotics and are frequently used in clinical practice for treating a variety of infections. This study sought to utilize pharmacoepidemiology methods and pharmacology principles to estimate the risk of macrolide treatment failure and quantify the influence of their pharmacokinetics on the risk of treatment failure, using clinically reported drug–drug interaction data. Using a large, commercial claims database (2006–2015), inclusion and exclusion criteria were applied to create a cohort of patients who received a macrolide for three common acute infections. Furthermore, an additional analysis examining only bacterial pneumonia events treated with macrolides was conducted. These criteria were formulated specifically to ensure treatment failure would not be expected nor influenced by intrinsic or extrinsic factors. Treatment failure rates were 6% within the common acute infections and 8% in the bacterial pneumonia populations. Regression results indicated that macrolide AUC changes greater than 50% had a significant effect on treatment failure risk, particularly for azithromycin. In fact, our results show that decreased or increased exposure change can influence failure risk, by 35% or 12%, respectively, for the acute infection scenarios. The bacterial pneumonia results were less significant with respect to the regression analyses. This integration of pharmacoepidemiology and clinical pharmacology provides a framework for utilizing real-world data to provide insight into pharmacokinetic mechanisms and support future study development related to antibiotic treatments.

Cross-roads for meta-analysis and network meta-analysis of H. pylori therapy

Helicobacter pylori infections are responsible for tremendous morbidity and mortality worldwide, leading to efforts to eradicate the organism. However, the effectiveness of antimicrobial therapy has been undermined by the progressive development of antimicrobial resistance. Treatments and treatment guidelines have been based on traditional pairwise meta-analyses of randomised controlled trials. More recently, network meta-analyses have also been used in an attempt to provide useful information to the clinician regarding which therapies appear best and which to avoid as the least efficacious. However, both forms of meta-analysis have been undermined by the same problems including the poor quality of the clinical trials using unoptimised regimens and incomparable comparisons related to marked geographic and ethnic genotypic and phenotypic heterogeneity. In addition, the comparator regimens often consist of invalid strawman comparisons. New approaches concerning H. pylori treatment and analysis of therapies are needed. H. pylori therapies should be based on antimicrobial stewardship, as in other infectious diseases. This approach requires the use of only optimised therapies proven to be reliably highly effective in the local population (eg, a cure rate of >90%) for both the study and the comparator regimens. Meta-analyses should be restricted to regimens that meet these criteria and must take into account the presence of marked geographical and host genetic and phenotypic heterogeneity. In addition, to provide clinically relevant results, treatment outcomes should focus on, and present, actual cure rates in addition to odd ratios.

The effectiveness of eradication therapy of the 1st line of Helicobacter pylori infection in patients with type 2 diabetes mellitus

Aim. Evaluation of the efficacy and safety of eradication therapy of infection Helicobacter pylori in patients with H. pylori- associated pathology of the upper gastrointestinal tract and concomitant type 2 diabetes mellitus (DM). Materials and methods. The prospective randomized study involving 180 patients (87 men and 93 women) with H. pylori- associated pathology of the upper gastrointestinal tract was carried out. The patients were divided into four groups of 45 people: 1 patients without diabetes who received the classic triple eradication therapy; 2 patients with type 2 DM who received the classic triple eradication therapy; 3 patients without DM who underwent quadrotherapy with bismuth preparations; 4 patients with type 2 DM who underwent quadrotherapy with bismuth preparations. Eradication therapy was carried out for 14 days. Evaluation of the effectiveness of eradication using a breath test was carried out 4 weeks after completion of the course of treatment. Eradication success was assessed separately for ITT and PP analyzes. Results. The effectiveness of classical triple eradication therapy in patients with concomitant type 2 DM is 64.4% in the ITT group and 69.05% in the PP: quadrotherapy 73.34 and 80.49%, respectively. The effectiveness of first line eradication therapy is higher in patients without DM compared with groups of patients with concomitant type 2 DM: ITT 83.33%, PP 88.23% and ITT 68.89%, PP 74.70%, respectively. The incidence of side effects in patients with type 2 DM: with the use of classical triple therapy 22.23%, quadrotherapy 31.12%. Conclusion. The data of the study of the efficacy and safety of line I eradication therapy make it possible to recommend the four-component therapy based on bismuth for use in clinical practice, especially in patients with DM.

Factors Affecting the Intraluminal Therapy for Helicobacter pylori Infection

Helicobacter pylori (H. pylori) can be eradicated immediately while conducting an endoscopic examination. The eradication rate of intraluminal therapy for H. pylori infection (ILTHPI) is 53.7% (51/95) via local application of single-dose medicament containing amoxicillin, metronidazole, and clarithromycin. We aimed to evaluate factors affecting ILTHPI and to assess the efficacy among single antibiotics, and compared our results with combined antibiotics. We enrolled H. pylori-infected treatment-naïve symptomatic patients; 95 completed triple-antibiotic ILTHPI were evaluated for risk factors, along with 60 completed mono-antibiotic ILTHPI containing amoxicillin, clarithromycin, or metronidazole in each of the 20 patients. Univariate analysis revealed the significant influence of BMI (OR: 1.15; 95% CI: 1.03–1.27, p = 0.011) and gastric juice pH (OR: 1.35; 95% CI: 1.16–1.58, p = 0.0001). Logistic regression analysis also showed significant influence of gastric juice pH (OR: 1.30; 95% CI: 1.10–1.54, p = 0.002). The eradication rate of mono-antibiotic ILTHPI is significantly lower than triple-antibiotic ILTHPI (11.7% vs. 53.7%; p < 0.0001; α = 0.05, power = 1.0). The efficacy was 20% (4/20) for metronidazole, 10% (2/20) for amoxicillin, and 5% (1/20) for clarithromycin. In conclusion, the level of gastric juice pH is a crucial factor affecting the ILTHPI. The detection of gastric juice pH and selection of optimal intraluminal medicaments are important. Further studies with combined antibiotics for ILTHPI, perhaps metronidazole-containing medicaments, are recommended.

10-Day and 14-day high-dose dual therapy for the treatment of Helicobacter pylori: A propensity score matching analysis

BACKGROUND

Inconsistent eradication rates for Helicobacter pylori have been reported worldwide with dual therapy, perhaps owing to the difference in dose administration and treatment duration. This retrospective study aimed to determine whether high-dose dual therapy (HDDT) with different regimens leads to different eradication rates. The study compares the efficacy and safety of HDDT 10-day vs 14-day and investigates the factors that might affect the eradication rates.

MATERIALS AND METHODS

Two comparable treatment groups were based on propensity score matching (PSM). Patients were divided into two groups based on the therapy they underwent: 10-day HDDT and 14-day HDDT (20 mg esomeprazole and 750 mg amoxicillin, administered four times daily). The eradication rates, adverse events (AEs), patient compliance, CYP2C19 gene polymorphisms, and antibiotic resistance rates of the two groups were compared.

RESULTS

The intention to treat (ITT) analysis showed that the eradication rates for 10-day and 14-day groups were 78.4% (95% CI 69.6%-87.2%) and 89.7% (95% CI 83.3%-96.2%; p = .039), respectively, while the per-protocol (PP) eradication rates were 80.0% (95% CI 71.3%-88.7%) and 92.9% (95% CI 87.4%-98.5%; p = .014), respectively. The corresponding drug-related AEs were 6.8% (6/88) and 5.7% (5/88; p = .755). No significant differences were observed between the compliance rates of the two groups. The CYP2C19 gene polymorphism had no effect on the eradication rates of the two groups.

CONCLUSION

The results showed that the 14-day HDDT affords a higher H. pylori eradication rate than the 10-day HDDT.

Impact of a hospital-wide computerised approach to optimise the quality of antimicrobial prescriptions in patients with severe obesity: a quasi-experimental study

Background

Rates of adherence to available recommendations for dose adjustments in patients with severe obesity are generally low. Hence, antimicrobials are often underdosed in these patients. Antimicrobial stewardship programmes can improve the use of antimicrobials in hospitalised patients. The aim of the study was to analyse the impact of an antimicrobial stewardship programme based on a computerised clinical decision support system for optimal dosing and antimicrobial use in inpatients with severe obesity.

Methods

This quasi-experimental retrospective study using interrupted time series was conducted in an academic centre in Canada from August 2008 to June 2018. The Antimicrobial Prescription Surveillance System was implemented in August 2010 (intervention 1) and specific rules targeting patients with class III obesity (body mass index ≥ 40 kg/m²) were added in June 2014 (intervention 2). Data were collected from all hospitalised adults receiving antimicrobials which required dose adjustment for severe obesity and were stratified by body mass index. Segmented regression analysis of interrupted time series was used to evaluate the impact of the Antimicrobial Prescription Surveillance System on the proportion of inappropriate days of therapy according to posology and on antimicrobial consumption.

Results

Overall, 65 205 antimicrobial prescriptions (68% non-obese, 25% class I-II obesity, and 7% class III obesity) were analysed. In patients with class III obesity, the intervention was associated with a decrease in the proportion of inappropriate days of therapy (trend after the first intervention, −0.8% per 2-month period [95% CI −1.1 to −0.5], p < 0.001; intercept, 11.3% [95% CI 8.2 to 14.5], p < 0.001), which led to a reduction of 35% over an eight-year period (from pre-intervention level of 19.1%). Intervention 1 resulted in a downward trend in antimicrobial consumption, followed by an increasing trend after intervention 2. In these patients, the most frequent interventions made by pharmacists targeted posology (46%).

Conclusions

Antimicrobial Prescription Surveillance System had a positive impact on dosing optimisation and antimicrobial consumption in patients with class III obesity. Improving antimicrobial prescriptions in these patients is important because suboptimal dosing could be associated with unfavourable outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06682-8.

Clinical symptoms are correlated with gastrojejunal anastomosis complications only during the first year after laparoscopic Roux-en-Y gastric bypass

INTRODUCTION

after laparoscopic Roux-en-Y gastric bypass (LRYGBP) many patients complain of epigastric pain or food intolerance, leading to the performance of upper gastrointestinal (UGI) endoscopy.

OBJECTIVE

this study aims to assess which symptomatology as reported by LRYGBP patients during follow-up suggested correlation with pathological findings of endoscopy, and which factors might play a role, taking the timing of symptom presentation into account.

MATERIALS AND METHODS

a retrospective cohort study was performed identifying LRYGBP patients presenting with food intolerance and/or epigastric pain who had undergone endoscopy. Primary outcomes were endoscopy findings, their association with patient characteristics, and timing of symptom presentation.

RESULTS

of the 514 patients complaining of epigastric pain and/or food intolerance, 81 (15.6 %) underwent endoscopy. A gastrojejunostomy complication was found in 58 % of cases. All patients who complained about food intolerance and epigastric pain presented pathological findings. The only preoperative factor associated with a gastrojejunostomy complication was being a smoker (p = 0.021). Time between surgery and endoscopy was also a predictive factor for endoscopic pathological findings (p = 0.007); in cases of epigastric pain, symptom onset during the first year (median: 10 months) was related to increased risk of gastrojejunal complications (p < 0.05).

CONCLUSIONS

endoscopies performed within one year of surgery were significantly more likely to reveal pathological findings than endoscopies performed after the first postoperative year, especially in patients experiencing epigastric pain.

Evaluation of Helicobacter pylori Genotypes in Obese Patients with Gastric Ulcer, Duodenal Ulcer, and Gastric Cancer: An Observational Study

INTRODUCTION

Obesity is a well-known risk factor for a variety of gastrointestinal disorders (GID). Helicobacter pylori is associated with different GID, such as gastric cancer and chronic gastritis. In this study, we investigated the prevalence of dominant genotypes in H. pylori isolated from obese patients diagnosed with gastric ulcer, duodenal ulcer, and gastric cancer.

METHODS

A total of 222 H. pylori-positive samples were collected from patients with obesity. GID and gastric cancer were identified by endoscopy and histopathology, respectively. Three biopsy specimens from the gastric antrum were obtained from each patient for culture tests, histological examination, and identification of vacuolating cytotoxin A (vacA) (vacA s1, vacA s2, vacA m1, vacA m2, vacA s1m1 vacA s1m2, vacA s2m1, and vacA s2m2), cagA, cagE, iceA1, oipA, dupA, and babA2 using polymerase chain reaction.

RESULTS

vacA, cagE, cagA, iceA1, oipA, dupA, and babA2 genes were detected in 222 (100%), 171 (77%), 161 (72.5%), 77 (34.6%), 77 (34.6%), 137 (61%), and 69 (31%) patients with obesity, respectively. Our findings revealed that vacA, iceA1, oipA, and babA2 were significantly associated with a higher risk of GID, while cagE, cagA, and dupA indicated no correlation with the development of GID. Also, in the combination of s- and m-region genotypes, s1m2 (79%) was the most frequently identified genotype in patients with obesity. A significant association was also found between cagA and the presence of vacA genotypes (except for vacA m1 and babA2).

CONCLUSIONS

This study indicated the high prevalence of different virulence genes in H. pylori isolated from obese patients and supported the significant role of H. pylori in the development of GID.

Cost Analysis in Helicobacter pylori Eradication Therapy Based on a Database of Health Insurance Claims in Japan

Objective

Cost-benefit is an important consideration for Helicobacter pylori (H. pylori) eradication in Japan, where 1.5 million patients were reported to receive first-line eradication annually. This study aimed to identify the optimal cost-saving triple therapy regimen for H. pylori eradication in Japan.

Materials and Methods

This retrospective observational study used data from a large-scale, nationwide health insurance claims database (2015‒2018). Using success rates of first-line eradication, mean total costs of first-line and second-line eradications per patient were compared between regimens including a potassium-competitive acid blocker (P-CAB) or a proton pump inhibitor (PPI), and between two clarithromycin (CAM) doses (400 and 800 mg/day). Subgroup analyses by smoking habit or body mass index (BMI) were performed.

Results

Among propensity score (age, gender, CAM dose, disease name)-matched patients (P-CAB regimen, n=22,002; PPI regimen, n=22,002), total costs were lower with the P-CAB than the PPI regimen (Japanese yen [JPY] 12,952 vs 13,146) owing to significantly higher first-line eradication rates with the P-CAB regimen (93.6% vs 79.7%; p<0.001). For both regimens, even among current smokers or patients with BMI ≥25 kg/m², eradication rates did not differ by CAM dose, and total costs were approximately JPY1000 lower with CAM 400 mg/day than with CAM 800 mg/day.

Conclusion

High success rate of first-line eradication contributes to saving in total eradication costs by reducing costs of subsequent therapy, irrespective of patients' smoking status or BMI class. The combination of more potent acid-inhibitory medicine and low-dose CAM may be the optimal regimen in terms of efficacy and cost-benefit in Japan.

The efficacy of Helicobacter pylori eradication in diabetics and its effect on glycemic control: A systematic review and meta-analysis

BACKGROUND AND AIMS

Previous studies have revealed the association between Helicobacter pylori (H. pylori) and diabetes mellitus, but conflicts still exist. The present study tried to investigate the underlying link between these two diseases by making comprehensive analyses of the impact of diabetes on H. pylori eradication and the influence of H. pylori eradication on diabetes.

METHODS

We systematically searched relevant studies from PubMed, Cochrane Library, Web of Science, and Embase updated to April 23, 2020. Studies examining the association between H. pylori eradication and diabetes were included. Pooled odds ratio (OR) and weighted mean differences (WMD) were calculated for different results.

RESULTS

Among the 2125 retrieved studies, 36 studies were included. Patients with type 2 diabetes mellitus (T2DM) have higher risk of H. pylori eradication failure than the non-diabetic one (OR = 2.59, 95% CI 1.82-3.70). Body mass index (BMI) was identified as a major factor affecting the efficacy of H. pylori eradication in diabetics, and better glycemic control was also found in eradication succeed patients (WMD: 0.51, 95% CI 0.20-0.81). Moreover, after eradication of H. pylori, improvement of HbA1c was proved (WMD = -0.33, 95% CI -0.65 to -0.02) in T2DM.

CONCLUSION

A higher risk of H. pylori eradication failure in T2DM was confirmed, and it was associated with BMI and glycemic control. Moreover, we also provided evidence that H. pylori eradication could improve glycemic control in patients with T2DM, which indirectly reflect the interaction between H. pylori and the diabetes.

Tailored Helicobacter pylori eradication therapy in obese patients undergoing bariatric surgery

OBJECTIVES

to compare the efficacy and safety of a tailored quadruple concomitant therapy based on body weight, with the same scheme but with fixed doses in obese patients undergoing bariatric surgery.

METHODS

a prospective study was performed of 104 obese patients.

RESULTS

the weight-based therapy group achieved significantly higher eradication rates in the intention-to-treat analysis; 86.3 % (95 % CI: 74.3-93.2) vs 66.1 % (95 % CI: 52.6-77.3), p < 0.05. Relative risk: 1.31 (95 % CI: 1.05-1.63). Discontinuations and adverse events were similar in both groups.

CONCLUSIONS

a tailored quadruple concomitant therapy based on body weight seems to be more effective than the standard quadruple concomitant therapy in obese patients.

Is Antimicrobial Dosing Adjustment Associated with Better Outcomes in Patients with Severe Obesity and Bloodstream Infections? An Exploratory Study

The impact of adjusted treatment on clinical outcomes in patients with severe obesity is unclear. This study included adults with severe obesity admitted for bloodstream infections between 2005 and 2015. The patients were grouped according to the percentage of the appropriateness of the dosage of their antimicrobial treatment: 80–100% = good, 20–79% = moderate, and 0–19% = poor. The association between antimicrobial adjustment and a composite of unfavourable outcomes [intensive care unit stay ≥72 h, duration of sepsis >3 days, length of stay ≥7 days or all-cause 30-day mortality] was assessed using logistic regression. Of 110 included episodes, the adjustment was rated good in 47 (43%) episodes, moderate in 31 (28%), and poor in 32 (29%). Older age, Pitt bacteremia score ≥2, sepsis on day 1, and infection site were independent risk factors for unfavourable outcomes. The level of appropriateness was not associated with unfavourable outcomes. The number of antimicrobials, consultation with an infectious disease specialist, blood urea nitrogen 7–10.9 mmol/L, and hemodialysis were significantly associated with adjusted antimicrobial dosing. While the severity of the infection had a substantial impact on the measured outcomes, we did not find an association between dosing optimization and better outcomes.

Screening Esophagogastroduodenoscopy Before Laparoscopic Sleeve Gastrectomy: Results in 819 Patients

Aim: The routine use of esophagogastroduodenoscopy (EGD) during the preoperative evaluation of surgical weight loss candidates is controversial. The aim of this study is to evaluate the findings of preoperative EGD in patients who are scheduled for a primary laparoscopic sleeve gastrectomy (LSG). The probable effect of these findings on the medical and surgical strategy that was followed is assessed. Methods: Findings of EGD obtained from consecutive LSG candidates and all data were prospectively recorded and retrieved from the database. Results: A total of 819 patients underwent EGD successfully. Mean age and body mass index were 38 ± 11.3 and 43.17 ± 7.2 kg/m², respectively. Fifty-eight percent were female. EGD of 263 (32.1%) patients was normal and 687 (84%) patients were asymptomatic. At least one abnormal finding was detected in 65% of the asymptomatic patients. Abnormal findings that did not change the surgical strategy were found in 550 patients (67.2%). Findings such as gastritis or duodenitis that changed the medical management before surgery were found in 309 patients (38.2%). Helicobacter pylori was positive in 218 (26.6%) patients but eradication treatment was not applied in the preoperative period. No pathology was detected that would create absolute contraindication or change the type of surgery in any patient. Only technical modifications were required in 13% due to hiatal hernia. The timing of the planned surgery has changed in only 6 patients (0.74%) (early stage neuroendocrine tumor, leiomyoma, severe ulcer). Conclusions: Routine EGD performed before LSG did not change the planned bariatric option in any patient, but led to 13% rate of technical modifications due to the presence of hiatal hernia. At least one abnormal finding was detected in 65% of asymptomatic patients. Due to endoscopic findings, the rate of patients who started medical acid-suppression treatment in the preoperative period was 38%.

Persistent infection of Helicobacter pylori affects weight loss in obese population compared with persistent negative: A case-control study based on healthy Chinese

BACKGROUND

The relationship between Helicobacter pylori (H pylori) and body mass index (BMI) is still inconclusive. Not only the high rate of H pylori infection but also the increasing higher BMI levels are endangering Chinese today.

METHODS

The aim of this research was to evaluate the association between different situations of H pylori infection and BMI values or levels in Chinese healthy population. A total of 39 091 individuals aged from 18 years to 80 years, performed healthy examination including a ¹³ C/¹⁴ C urease breath test (¹³ C/¹⁴ C-UBT), were included. Among them, 30 224 individuals only had one time of health examination, and 8867 had two or more times. A case-cohort data of 8752 with an interval time more than 6 months, collected by the first and the last time, were established from the latter. BMI groups are classified according to the China recommendation: low weight (<18.5 kg/m² ), normal weight (18.5 ~ 23.9 kg/m² ), overweight (24.0 ~ 27.9 kg/m² ), and obesity (≥28.0 kg/m² ).

RESULTS

The rate of H pylori infection among low weight, normal weight, overweight, and obesity was 43.2%, 44.7%, 46.4%, and 48.0%, respectively (P = .000). H pylori infection increased the risk of higher level of BMI (OR = 1.077, 95% confidence interval = 1.036-1.119, χ²  = 14.048, P = .000) with adjustments for sex and age. In the case-control study, the rate of persistent negative, persistent infection, new infection, and eradicated infection was 39.5%, 25.8%, 15.8%, and 18.9%, respectively, with a median interval time of 13 months. The mean obesity BMI descend values in the persistent negative subgroup were lower than those in the persistent infection subgroup (-0.21 ± 1.19 kg/m² vs -0.003 ± 1.01 kg/m² , P = .021). But the change of BMI classifications had no difference between the subgroups of H pylori infection in different BMI levels.

CONCLUSIONS

H pylori infection was positively correlated with higher BMI levels. And H pylori persistent infection had a negative effect on the fall of BMI values in Chinese obese population.

Comparison of 10-Day Course of Triple Therapy Versus 14-Day Course for Eradication of Helicobacter pylori Infection in an Indonesian Population: Double-Blinded Randomized Clinical Trial

Objective:

The aim of this study was to compare the effectiveness of 10-day course of triple therapy versus a 14-day course in the treatment of H.pylori infection in an Indonesian population.

Methods:

A double-blinded randomized clinical trial was included patients, Indonesian population, with H.pylori infection conducted in Cipto Mangunkusumo Hospital, Jakarta; Cilincing District General Hospital, Jakarta; and West Nusa Tenggara General Hospital, Mataram, during October 2016 - April 2017. Patients were randomized to be given triple therapy as Rabeprazole 20 mg, Amoxicillin 1,000 mg, and Clarithromycin 500 mg twice daily, for 14 days or 10 days plus 4 days placebo. Eradication was evaluated with UBT at least 4 weeks after completion the therapy.

Results:

A total of 75 patients (38 in the 14-day group and 37 in the 10-day group) were included to the study. In the intention-to-threat analysis, eradication rate was 67.6% (95% CI. 52.5%-82.6%) for the 10-day group versus 86.8% (95% CI. 76.0%-97.5%) for the 14-day group (p = 0.046), whereas per protocol analysis obtained 73.5% (95% CI. 58.6%-88.3%) for the 10-day versus 91.9% (95% CI. 84.1%-99.6%) in the 14-day group (p = 0.039). Adverse events were not significantly different between the two groups.

Conclusion:

A 14-day course was more effective than 10-day course of triple therapy as first-line for eradication of H.pylori infection in an Indonesian population.

Self-reported adverse drug effects and associated factors among H. pylori infected patients on standard triple therapy: Prospective follow up study

Background

One of the most common reasons for poor medication adherence and associated treatment failure of triple therapy is adverse drug effect (ADEs) of medications.

Objective

Assessment of ADEs and associated factors during H. pylori eradication therapy.

Method

Consented H. pylori positive adult outpatients on standard triple therapy (proton pump inhibitor, amoxicillin and clarithromycin) were involved in this facility based follow up study from May 2016 to April 2018 at Bahir Dar city in Ethiopia. Pre-developed questionnaire and formats were used to collect sociodemographic, medical information, and patient practice data before, during, and after therapy. Bivariate and backward stepwise multivariate logistic regression was used to analyze data. P-value < 0.05 at 95%CI was considered as significant.

Result

A total of 421 patients were involved in the study. Almost 80% of the patients were urban residents. Mean (±SD) age and body weight of patients were 30.63 (± 10.74) years and 56.79 (± 10.17) kg, respectively. ADE was reported from 26.1% of the patients and of all the reported ADEs, more than 85% was manifested with gastrointestinal symptoms which include gastrointestinal discomfort(39.1%), nausea (13.6%), constipation(12.7%), diarrhea(12.9%) and anorexia(10%). Determinants of self-reported ADEs among patients in the present study were body mass index above 25 (AOR: 2.55; 95%CI (1.21–5.38), p = 0.014), duration of acid-pepsin disorder more than 3weeks (AOR: 3.57; 95%CI (1.63–7.81), p = 0.001), pain feeling during long interval between meals (AOR: 2.14; 95%CI (1.19–3.84), p = 0.011), and residence in urban area (AOR: 1.95; 95% CI (1.04–3.67), p = 0.038).

Conclusion

Significant proportion of patients reported ADEs which commonly manifested with gastrointestinal symptoms. Consideration of patients’ body mass index, duration of the disorder, period of the day when patients feel pain, and patients’ area of residence could help to reduce ADEs experienced during H. pylori eradication therapy.

Helicobacter pylori eradication rate of standard triple therapy and factors affecting eradication rate at Bahir Dar city administration, Northwest Ethiopia: A prospective follow up study

BACKGROUND

Eradication of Helicobacter pylori infection with standard triple therapy has been accepted to curb associated risks of chronic gastritis andpeptic ulcer disease.

OBJECTIVE

To assess H. pylori eradication rate of standard triple therapy and patient related factors affecting eradication rate.

METHODS

A facility based prospective follow up study was conducted in Bahir Dar City Administration, Ethiopia, on consented outpatients presented with gastritis and peptic ulcer disease and positive for H. pylori stool antigen test from May 2016 to April 2018. Eradication was confirmed with stool antigen test made after 4-6 weeks of standard triple therapy, comprising of proton pump inhibitor, clarithromycin and amoxicillin. Pre-developed questionnaire and data collection formats were used to collect variables before and after therapy. Bivariate and backward stepwise multivariate logistic regression was used to analyze data. P-value < 0.05 at 95%CI was considered as significant.

RESULTS

The overall H. pylori eradication rate was 90.3% (379/421). Almost 80% of the patients were urban residents. Mean (±SD) age and body weight of patients were 30.63 (± 10.74) years and 56.79 (± 10.17) kg, respectively. Self-reported adverse drug effects and area of residence of patients were factors affecting eradication rate significantly. Patients with no self-reported adverse drug effect were 3.85 (AOR: 3.85; 95%CI (1.41-5.26)) times more likely to eradicate H. pylori infection compared to those reported adverse effects. Patients living in rural area were 2.7 (AOR: 2.7; 95%CI (1.19-20.0)) times more likely to achieve eradication compared to urban residents.

CONCLUSION

H. pylori eradication rate is within the recommended level for clinical practice, indicating that modifications of the standard triple therapy observed in the different healthcare institutions are not evidence-based. Emphasis should be given to adverse drug effects of medications and tailored counseling based on area of residence could have a contribution in improving eradication rate.

Half-dose clarithromycin-containing bismuth quadruple therapy is effective and economical in treating Helicobacter pylori infection: A single-center, open-label, randomized trial

BACKGROUND

Clarithromycin-containing bismuth quadruple therapy has been recommended as the first-line therapy for H pylori infection in China. However, its expensive cost and high antibiotic-related adverse reactions are always haunting us. To find a safer, more cost-effective, and high eradicative strategy for Helicobacter treatment, we investigated the efficacy of 14-day bismuth quadruple therapy and different doses of clarithromycin in the first-line treatment.

METHOD

A total of 210 patients with H pylori infection were recruited and randomly assigned to half-dose clarithromycin group (esomeprazole 20 mg bid, amoxicillin 1 g bid, clarithromycin 250 mg bid, and bismuth potassium citrate 0.6 g bid) for 14 days or standard-dose clarithromycin group (esomeprazole 20 mg bid, amoxicillin 1 g bid, clarithromycin 500 mg bid, and bismuth potassium citrate 0.6 g bid) for 14 days. A ¹³ C-urea breath test (¹³ C-UBT) was performed at least 4 weeks after treatment. The eradication rate of H pylori, the incidence of side effects, and the cost-effectiveness of regimens were evaluated in this study.

RESULTS

The eradication frequencies were 86.67% for both groups in the intention-to-treat analysis, while the per-protocol eradication rates were 91% vs. 91.92% (p=0.817). The incidence of adverse events was higher in standard dose group (54.21% vs. 34.29%; p=0.004), especially bitter taste symptom. There was a higher level of costs per person associated with the standard-dose group as compared with half-dose group (￥804.3 vs ￥654.36). The cost-effectiveness ratio of the half dose was less than that of the standard dose (7.55 vs 9.16 CNY per percent).

CONCLUSIONS

A 14-day half-dose clarithromycin-containing bismuth quadruple regimen is as effective as the standard bismuth quadruple therapy at eradicating H pylori, which is better tolerated and more economical. (ChiCTR-ROC-15007406).

Helicobacter pylori Antimicrobial Susceptibility Testing-Guided Salvage Therapy in the USA: A Real Life Experience

BACKGROUND

The current practice guidelines recommend that Helicobacter pylori (H. pylori) culture and antimicrobial susceptibility testing (AST) be considered after patients failed the second course of H. pylori eradication therapy.

AIMS

Here we report the real life experience of following this recommendation in the USA.

METHODS

We established an in-house H. pylori culture protocol for AST and identified retrospectively patients who previously failed ≥ 2 courses of anti-H. pylori therapy and underwent esophagogastroduodenoscopy with AST at University of Michigan from 2010 to 2017. We determined the rate of H. pylori antibiotic resistance, the success rates of AST-guided tailored therapy, and the risk factors associated with treatment failure.

RESULTS

Forty-seven patients were identified and 34 (72.3%) had successful cultures and AST. The most common antibiotic resistance was to metronidazole (79.4%), followed by clarithromycin (70.6%) and ciprofloxacin (42.9%). None of the patients were resistant to amoxicillin or tetracycline. The overall success rate of AST-guided tailored therapy was low (44.4%, 12/27). In patients infected with metronidazole-resistant H. pylori, bismuth quadruple therapy appears to be superior compared to non-bismuth quadruple therapy (6/8 or 75.0% vs. 3/14 or 21.4%, P = 0.03). High body mass index was significantly associated with tailored therapy failure (OR 1.24, 95% CI 1.00-1.54, P = 0.049).

CONCLUSIONS

The success rate of AST-guided salvage therapy in the USA is low particularly in those with high BMI. Bismuth-based therapy appears to be better than non-bismuth-based regimens.

Preoperative Endoscopy Prior to Bariatric Surgery: a Systematic Review and Meta-Analysis of the Literature

BACKGROUND

There is debate regarding preoperative endoscopy (EGD) in patients undergoing bariatric surgery. Some centers perform EGD routinely in all patients; others perform EGD selectively. The objective of this study was to perform a systematic review and meta-analysis of the existing literature to estimate how frequently preoperative EGD changes management.

METHODS

Our review yielded 28 studies encompassing 6616 patients. Baseline characteristics including age and body mass index (BMI) were included. Patients were grouped based on EGD findings into two groups: Group 1-findings which did not significantly change management (e.g., mild/moderate duodenitis, Grade A/B esophagitis, mild/moderate gastritis, H. pylori infection, hiatal hernia <2 cm); Group 2-findings which delayed, altered, or cancelled surgery (e.g., severe duodenitis, Grade C/D esophagitis, gastric varices, hiatal hernia >2 cm, mass/carcinoma). A general estimating equation (GEE) model accounting for the correlated data within each study was used to calculate confidence intervals around the estimate of how frequently surgery was delayed or altered.

RESULTS

Mean age was 41.4 ± 2.9 years, the majority was women, and mean preoperative BMI was 47 ± 3.2 kg/m². Overall 92.4 % (n = 6112) had a normal EGD or findings that did not change clinical management and 7.6 % (n = 504); 95 % CI [4.6, 12.4 %] had findings that delayed/altered surgery. The revised estimate was 20.6 %; 95%CI [14.5, 28.2 %] if all esophagitis (regardless of grade) were categorized into Group 2. The approximate incidence of Barrett's esophagus and carcinoma were 0.1 and 0.08 %, respectively.

CONCLUSION

A selective approach to preoperative EGD may be considered, based on the patients' symptoms, risk factors, and type of procedure planned.

Efficacy and tolerability of culture-guided treatment for Helicobacter pylori infection

OBJECTIVE

The aim of this study was to evaluate the efficacy/tolerability of a culture-guided approach in the eradication of Helicobacter pylori and identify factors associated with antibiotic resistance/treatment failure.

PATIENTS AND METHODS

This retrospective single-center study included patients who underwent culture-guided treatment for H. pylori infection, after two ineffective eradication attempts, between October 2012 and December 2016. We assessed the following demographic and clinical data of the patients: sex, age, BMI, alcohol and tobacco consumption, history of dyspepsia, peptic ulceration and first-degree relatives with gastric cancer, antibiotic susceptibility results, treatment composition, tolerability, and success. The treatment success was confirmed by a monoclonal stool antigen test.

RESULTS

Culture-guided treatment was performed in 42 patients (57% women, mean age±SD: 48.9±11.4 years). The rates of antibiotic resistance were as follows: clarithromycin 86%, metronidazole 67%; levofloxacin 52%, tetracycline 2%, and amoxicillin and rifampicin 0%. Double resistance to clarithromycin and metronidazole was found in 59.5% of the patients. Most patients showed resistance to less than three antibiotics, but 31% were resistant to three or more. Intention-to-treat and per-protocol eradication rates were 59.5 and 61.5%. Adverse events occurred in 15 (35.7%) patients, but only two (4.8%) patients did not complete treatment because of adverse events. Only age more than 50 years was associated with resistance to three or more antibiotics. Having a first-degree relative with gastric cancer was associated with treatment failure and having a BMI of at least 25 kg/m protected from failure.

CONCLUSION

Third-line culture-guided treatment often fails to eradicate H. pylori infection. We need to find factors other than in-vitro antibiotic resistance to explain these suboptimal results.

Efficacy and Safety of the Triple Therapy Containing Ilaprazole, Levofloxacin, and Amoxicillin as First-Line Treatment in Helicobacter pylori Infections

Background and Aims. To establish the efficacy and safety of ilaprazole, levofloxacin, and amoxicillin as a first-line eradication treatment for Helicobacter pylori. Methods. Patients with gastric ulcer, duodenal ulcer, or gastritis, as detected by esophagogastroduodenoscopy with confirmed H. pylori infection between September 2014 and November 2015, were enrolled in the study. All participants received ilaprazole (10 mg bid), levofloxacin (500 mg bid), and amoxicillin (1000 mg bid) for 10 days. H. pylori eradication was confirmed by a ¹³C-urea breath test at 6–8 weeks after the end of treatment. Results. Of 84 patients included in the analysis, the eradication rate was 88.8% in the per protocol group (n = 80). Demographic factors such as age, gender, body mass index (BMI), alcohol, smoking, hypertension, diabetes mellitus, and peptic ulcer did not affect the eradication rate. However, multivariate analysis showed that overweight patients and patients with cerebrovascular accident (CVA) had a significantly lower eradication rate than patients with normal BMI and without CVA. Laboratory test results did not change significantly after treatment. A total of six (7.5%) patients developed eight adverse reactions. Conclusions. A 10-day triple therapy containing ilaprazole, levofloxacin, and amoxicillin is a safe alternative first-line eradication treatment for H. pylori.

Loose ends in the eradication of Helicobacter pylori infection

The eradication of Helicobacter pylori is essential for prevention and treatment of various conditions associated with this infection. However, its effectiveness is limited and influenced by factors linked to the bacteria and the host. In particular, influence of the biotype, smoking, diabetes mellitus, and previous treatment failure in eradication is understudied. Our center proposed to evaluate these aspects in a real life cohort by applying a questionnaire with demographic and lifestyle variables in patients who consecutively underwent urease breath test after the eradication therapy.

The oesophageal microbiome: an unexplored link in obesity-associated oesophageal adenocarcinoma

The influence of diets rich in saturated fats and simple sugars on the intestinal microbiota plays a central role in obesity. Being overweight or obese predisposes individuals to several diseases including oesophageal adenocarcinoma (OAC), which develops through a cascade of events starting with gastro-oesophageal reflux disease, progressing to Barrett's oesophagus (BO), and then OAC. A range of mechanisms for the increased risk of OAC in obese individuals have been proposed; however, a role for the oesophageal microbiota has been largely ignored. This is despite the fact that it is clear that the composition of the oesophageal microbiota shifts with the development of OAC. Given the well-established impact that unhealthy diets have on the intestinal microbiota, it is plausible that exposure to unhealthy foods, and the ensuing obesity, would result in an imbalance in the oesophageal microbiota. It is also likely that these changes may mimic the changes observed in the intestinal microbiota (i.e. increase in short-chain fatty acid (SCFA) producers and bile acid biosynthesis). The modulation of SCFAs and bile acids in the oesophagus by diet could promote the transdifferentiation from squamous to intestinal-like columnar cells observed in BO, given that intestinal cells proliferate in the presence of SCFAs.

Severe gastritis decreases success rate of Helicobacter pylori eradication

BACKGROUND

In several studies, different risk factors other than antibiotic resistance have been documented with Helicobacter pylori eradication failure. We aimed in this study to investigate the relationship of gastric density of H. pylori, the occurrence/degree of gastric atrophy, and intestinal metaplasia (IM) with success rate of H. pylori eradication.

METHODS

Two hundred consecutive treatment naive patients who received bismuth containing standart quadruple treatment due to H. pylori infection documented by histopathological examination of two antral or two corpal biopsies entered this retrospective study. The updated Sydney system was used to grade the activity of gastritis, density of H. pylori colonization, atrophy, and IM. Stages III and IV of operative link for gastritis assessment (OLGA) or the operative link on gastric intestinal metaplasia assessment (OLGIM) stages was considered as severe gastritis. H. pylori eradication was determined via stool H. pylori antigen test performed 4 weeks after the end of therapy.

RESULTS

The presence of gastric atrophy and IM was significantly higher in patients with eradication failure (p = 0.001 and 0.01, respectively). Severe gastritis (OLGA III-IV and OLGIM III-IV) rates were higher in eradication failure group. A multiple linear regression analysis showed that OLGA and OLGIM stages were to be independent risk factors for eradication failure (p = 0.03 and 0.01, respectively).

CONCLUSION

Our results suggested that histopathologically severe gastritis may cause H. pylori eradication failure. In addition, we found that H. pylori density was not a risk factor for treatment failure in patients who receive quadruple treatment.

Is There Any Difference in the Eradication Rate of Helicobacter pylori Infection According to the Endoscopic Stage of Peptic Ulcer Disease?

BACKGROUND

The eradication rate of Helicobacter pylori (H. pylori) infection might be affected by the degree of inflammation of gastric mucosa represented by the endoscopic stage of peptic ulcer disease (PUD). The aims of this study were to evaluate the eradication rates of H. pylori infection according to the endoscopic stage of PUD and to document whether early eradication in the active stage could yield a higher eradication rate in patients with peptic ulcer bleeding (PUB).

MATERIALS AND METHODS

A total of 1,177 patients with PUD (380 gastric ulcer, 710 duodenal ulcer, and 87 combined ulcer) who received proton-pump inhibitor (PPI)-based triple therapy were included, and the eradication rates were compared by ulcer stage. Univariate and multivariate analyses were conducted to identify factors influencing eradication rate. In PUB, the eradication rates between the early eradication group (≤7 days) and the late eradication group (>7 days) were compared.

RESULTS

The eradication rates according to endoscopic stage were significantly different in gastric ulcer (active vs healing vs scarring; 84.8% vs 82.7% vs 70.6%, p = .014, respectively), but there were no significant differences in duodenal ulcer (active vs healing vs scarring; 87.6% vs 80.9%% vs 80.9% p = .169, respectively). In multivariate analyses, active ulcer as well as age younger than 50 was a significantly independent predictor of successful eradication (Odds ratio; 2.799, 95% CI; 1.659-4.723, p = .0001). The eradication rate of the early eradication group was significantly higher than the late eradication group in PUB (89.2% vs 71.9%, 95% CI; 1.265-8.269, p = .011).

CONCLUSIONS

There was a significant difference in the eradication rate according to the endoscopic stage of gastric ulcer. Active ulcer was an independent predictor of successful eradication. Furthermore, early H. pylori eradication should be considered in patients with PUB to yield a higher eradication rate.

Interaction of obesity and infections

There is evidence that certain infections may induce obesity. Obese persons may also have more severe infections and have compromised response to therapies. The objective of this study is to review the available literature identifying infections that potentially contribute to greater body mass index (BMI) and differential responses of overweight and obese persons to infections. A systematic literature review of human studies examining associations between infections and weight gain, differential susceptibility, severity, and response to prevention and treatment of infection according to BMI status (January 1980-July 2014) was conducted. Three hundred and forty-three studies were eligible for inclusion. Evidence indicated that viral infection by human adenovirus Ad36 and antibiotic eradication of Helicobacter pylori were followed by weight gain. People who were overweight or obese had higher susceptibility to developing post-surgical infections, H1N1 influenza and periodontal disease. More severe infections tended to be present in people with a larger BMI. People with a higher BMI had a reduced response to vaccinations and antimicrobial drugs. Higher doses of antibiotics were more effective in obese patients. Infections may influence BMI, and BMI status may influence response to certain infections, as well as to preventive and treatment measures. These observations have potential clinical implications.

Treatment of community-acquired pneumonia

Community-acquired pneumonia is the sixth leading cause of death in the USA. Adherence to the 2007 Infectious Diseases Society of America/American Thoracic Society community-acquired pneumonia guidelines has been associated with improved clinical outcomes. However, choice between guideline-recommended treatments is at the discretion of the prescribing clinician. This review is intended to discuss the characteristics of these treatment options including dosing frequency, dose adjustment for renal/hepatic dysfunction, serious/common adverse events, drug interactions, lung penetration, pharmacokinetic-pharmacodynamic target and effect of obesity to help guide antimicrobial selection. An increasing portion of patients are receiving expanded empiric coverage for methicillin-resistant Staphylococcus aureus as recommended by the American Thoracic Society and Infectious Diseases Society of America for healthcare-associated pneumonia. However, this expanded coverage may not be achieving the desired improvements in clinical outcomes. We expect this increasingly diverse spectrum of patients with pneumonia to eventually result in the merger of these two guidelines to include all patients with pneumonia.

Prevalence of Helicobacter pylori infection and its relation with body mass index in a Chinese population

BACKGROUND

Helicobacter pylori infection is highly prevalent worldwide. The association between obesity and H. pylori infection is controversial in the literature. This study aims to investigate the prevalence of H. pylori infection and its relation with body mass index (BMI) in a Chinese population.

MATERIALS AND METHODS

A cross-sectional study was performed among adults who underwent health checkups at the First Affiliated Hospital, College of Medicine, Zhejiang University in 2013. The prevalence of H. pylori infection was examined by (13)C urea breath tests, and the association between prevalence of H. pylori infection and BMI was analyzed.

RESULTS

Of the 8820 participants enrolled, 3859 (43.8%) were positive for H. pylori infection. H. pylori-positive participants had a more unfavorable metabolic profile than H. pylori-negative participants. Overweight/obese participants showed a higher prevalence of H. pylori infection than that of lean participants, and a positive linear correlation between BMI and prevalence of H. pylori infection was observed. Both unadjusted and adjusted analysis revealed that BMI was significantly associated with risk factors of H. pylori infection.

CONCLUSIONS

Our results showed that BMI was significantly and positively associated with H. pylori infection, and a high BMI was associated with an increased risk of the infection.

Are clinical features able to predict Helicobacter pylori gastritis patterns? Evidence from tertiary centers

Outcome of Helicobacter pylori infection is different according to gastritis extension (i.e. antrum-restricted gastritis or pangastritis). The aim of this study is to evaluate whether different gastritis patterns are associated with specific gastrointestinal symptoms or clinical signs that could be suggestive of the topography of gastritis. 236 consecutive symptomatic outpatients were recruited in two tertiary centers. They filled in a validated and self-administered Rome III modular symptomatic questionnaire, and underwent gastroscopy with histological sampling. 154 patients with Helicobacter pylori infection were included. Clinical presentation did not differ between antrum-restricted gastritis and pangastritis, gastro-esophageal reflux disease being present in 48.2 and 54.1 % of patients and dyspepsia in 51.8 and 45.9 %, respectively. However, pangastritis statistically differed from antrum-restricted gastritis in that the presence of clinical signs (p < 0.0001) was observed in 33.7 % of the patients, consisting of iron deficiency (31.6 %), iron deficiency-anemia (20.4 %) and levothyroxine malabsorption (3.1 %). Symptoms are not helpful in suggesting gastritis pattern whereas their association with signs, accurately detected, is indicative for the presence of pangastritis.

Brain-gut axis in the pathogenesis of Helicobacter pylori infection

Helicobacter pylori (H. pylori) infection is the main pathogenic factor for upper digestive tract organic diseases. In addition to direct cytotoxic and proinflammatory effects, H. pylori infection may also induce abnormalities indirectly by affecting the brain-gut axis, similar to other microorganisms present in the alimentary tract. The brain-gut axis integrates the central, peripheral, enteric and autonomic nervous systems, as well as the endocrine and immunological systems, with gastrointestinal functions and environmental stimuli, including gastric and intestinal microbiota. The bidirectional relationship between H. pylori infection and the brain-gut axis influences both the contagion process and the host’s neuroendocrine-immunological reaction to it, resulting in alterations in cognitive functions, food intake and appetite, immunological response, and modification of symptom sensitivity thresholds. Furthermore, disturbances in the upper and lower digestive tract permeability, motility and secretion can occur, mainly as a form of irritable bowel syndrome. Many of these abnormalities disappear following H. pylori eradication. H. pylori may have direct neurotoxic effects that lead to alteration of the brain-gut axis through the activation of neurogenic inflammatory processes, or by microelement deficiency secondary to functional and morphological changes in the digestive tract. In digestive tissue, H. pylori can alter signaling in the brain-gut axis by mast cells, the main brain-gut axis effector, as H. pylori infection is associated with decreased mast cell infiltration in the digestive tract. Nevertheless, unequivocal data concerning the direct and immediate effect of H. pylori infection on the brain-gut axis are still lacking. Therefore, further studies evaluating the clinical importance of these host-bacteria interactions will improve our understanding of H. pylori infection pathophysiology and suggest new therapeutic approaches.

Second and third line treatment options for Helicobacter pylori eradication

Helicobacter pylori is a highly successful bacterium with a high global prevalence and the infection carries significant disease burden. It is also becoming increasingly difficult to eradicate and the main reason for this is growing primary antibiotic resistance rates in a world where antibiotics are frequently prescribed and readily available. Despite knowing much more about the bacterium since its discovery, such as its genomic makeup and pathogenesis, we have seen declining treatment success. Therefore, clinicians today must be prepared to face one, two or even multiple treatment failures, and should be equipped with sufficient knowledge to decide on the appropriate salvage therapy when this happens. This article discusses the factors contributing to treatment failure and reviews the second and third-line treatment strategies that have been investigated. Established empiric second line treatment options include both bismuth based quadruple therapy and levofloxacin based triple therapy. Antibiotic testing is recommended prior to initiating third line treatment. In the event that antibiotic susceptibility testing is unavailable, third line treatment options include rifabutin, rifaximin and sitafloxacin based therapies.