First-line treatment of Helicobacter pylori in Lebanon: Comparison of bismuth-containing quadruple therapy versus 14-days sequential therapy

Clinical features and temporal trends in H. pylori negative gastric maltoma

BACKGROUND

Mucosa-Associated Lymphoid Tissue (MALT) lymphoma or MALToma is a type of non-Hodgkin lymphoma arising in the gastric mucosa that has largely been associated with Helicobacter pylori (H. pylori) infection. However, less than 10% of gastric MALTomas can occur with a negative H. pylori status, and the disease seems to have a different course.

PATIENTS AND METHODS

Patients diagnosed with MALToma from 2000 to 2021 were included in the study. H. pylori-negative (HPN) status was confirmed when patients had at least 2 negative tests among the following: urea breath test, rapid urease test, serological test, or histology. The patients were divided into H. pylori positive (HPP) and HPN groups.

RESULTS

The final analysis included 52 gastric MALToma patients, 25 (48.1 %) were HPN. Demographics and disease stages were comparable between the two groups, although a higher prevalence of HPN cases emerged in patients diagnosed from 2011 to 2021 compared to the 2000-2010 period (55.3 % vs. 28.6 %, p = 0.09). All patients in the HPP group received eradication therapy (ET) compared to only 40 % in the HPN group. ET success in the stage 1 HPN group was 25 % compared to 78.6 % in the HPP group (p = 0.03). More patients in the HPN group received chemo and/or radiotherapy compared to the HPP (86.4 % vs 57.1 %, p = 0.033). Treatment outcomes were similar between both groups. Comparing stage 1 MALToma patients who responded to ET versus non-responders revealed that responders were more likely to be HPP (76.8 % vs. 33.3 %, p = 0.026) and diagnosed in the earlier period (2000-2010, p = 0.048).

CONCLUSION

HPN MALToma patients were similar to HPP patients in clinical features. However, there was an increase in diagnosis of HPN MALToma and a decrease in response to ET in more recent years.

Seroprevalence of Helicobacter pylori among dyspeptic patients in northern Lebanon: a 6-year retrospective study in two tertiary hospitals

Helicobacter pylori causes chronic gastritis and plays a significant role in duodenal/gastric ulcer disease and gastric cancer. Its prevalence varies among different populations and geographical areas. Here, in a hospital-based retrospective study, we investigated the seroprevalence of H. pylori infection in northern Lebanon. We examined the records of 4000 consecutive dyspeptic patients attending 2 tertiary care centres in the North (Tripoli) and Akkar (Halba) governorates. Seropositivity for H. pylori was determined using enzyme immunoassays investigating specific anti- H. pylori IgG antibodies. The association of infection with the available patients' demographic characteristics was also evaluated. The mean age of our study population was 36.9±16.6 years. With 2486 female and 1514 male subjects, the overall female/male ratio was 1.64. In total, H. pylori seropositivity was detected in 1367/4000 (34.2 %) tested individuals. The multivariate logistic regression analysis showed that H. pylori infection is less prevalent in female than in male examined patients [adjusted odds ratio (OR): 0.84; 95 % confidence interval (CI): 0.73-0.96; P<0.013]. Seroprevalence gradually increased with age - from 14.6 % in patients below 18 years to 42.9 % in those above 49 years - and was significantly higher among Akkar patients compared to those from the North governorate: 49.6 versus 28.7 %, respectively (P<0.001). Overall, a third of symptomatic patients in northern Lebanon are infected with H. pylori . However, the prevalence of infection was markedly different in close geographical zones in this region. Additional screening studies using different screening methods are needed in the future to determine the accurate prevalence of this bacterium and its clinical implications to establish efficient national intervention strategies.

The pharmacotherapeutic management of duodenal and gastric ulcers

INTRODUCTION

Although the incidence and prevalence of duodenal and gastric ulcers have been declining, it remains challenging for health care systems. Based on the underlying cause, history, and characteristics of ulcers, management is generally provided by administering proton pump inhibitors (PPIs) or antibiotics.

AREAS COVERED

This article is based on global guidelines and English language literature from the past decade obtained through searches using PubMed, Clinicaltrials.gov, the US FDA, and the Cochrane library. Using a stepwise approach, dose and duration of treatment, drug interactions, warnings and contraindications, adverse effects, and administration points were specified. New drug candidates that may get American and European approvals were also introduced.

EXPERT OPINION

Despite the wide use of PPIs, their development lags behind the clinical need. There is an absolute requirement to develop third-generation PPIs with higher potency and improved pharmacokinetic and safety profiles. Regarding the antibiotic resistance crisis, including those used against H. pylori, conducting more clinical trials and investigating regional antibiotic resistance are warranted. Potassium competitive acid blockers, ilaprazole, and an H. pylori vaccine all show promise for the future.

Helicobacter pylori Infection in Tripoli, North Lebanon: Assessment and Risk Factors

Helicobacter pylori (H. pylori) infection occurs among half of the general population worldwide, with high geographic variability. Even though H. pylori is the leading cause of several gastric diseases, ranging from gastritis and peptic ulcers to gastric malignancies, such as gastric cancer and mucosa-associated lymphoid tissue lymphoma, most of the infections remain asymptomatic. Early detection and eradication of H. pylori can definitely prevent severe long-term gastric diseases associated with H. pylori. In Lebanon, the prevalence of H. pylori is not well documented, especially in healthy subjects. The aim of this study is to assess H. pylori infections and the associated risk factors in Tripoli, North Lebanon. A cross-sectional study was conducted on 300 healthy Lebanese volunteers, including both children and adults. The H. pylori stool antigens were detected using the Premier Platinum HpSA test. The socio-demographic data, lifestyle characteristics, and gastrointestinal characteristics of all participants were analyzed. Out of the 300 tested volunteer subjects, 31% were found to be positive for H. pylori. A multivariate binary logistic regression analysis for factors associated with H. pylori infection revealed a significant association between H. pylori infection and gastrointestinal disturbances, the crowding index, and occupation. A significant statistical correlation was found between sheesha smoking (p = 0.001) and H. pylori infection. These findings highlight the need for the development of preventive approaches and strategic indications for the appropriate treatment of H. pylori infections in Tripoli, North Lebanon.

Molecular diagnosis of Helicobacter pylori antibiotic resistance in the Taif region, Saudi Arabia

Success in eradication of Helicobacter pylori is declining globally because H. pylori has developed resistance against most of the antibiotics proposed for eradication regimens, mainly through point mutations. The present study included 200 patients with dyspepsia attending Taif Hospital. Gastric biopsies were obtained during gastroscopy and subjected to rapid urease testing. Molecular methods were used to confirm diagnoses of H. pylori infection and to identify resistance gene variants of four antibiotics; namely, clarithromycin, metronidazole, fluoroquinolones and tetracycline (23S rRNA, gyrA, rdxA and 16S rRNA respectively). Of all investigated patients, Molecular diagnoses were made in 143 of all investigated patients; thus, the prevalence was .5%. The overall rate of resistance to clarithromycin among the H. pylori-positive patients was high (39.9%) and the rate of resistance significantly greater (48.2%) among the secondary resistance group, secondary resistance being defined as resistance as a result of previous exposure to the relevant antibiotic. The rate of resistance to fluoroquinolones was considered moderate; the difference in rate of resistance between the primary and secondary resistance groups (8.4% and 9.5%, respectively) was not significant Also, there was a low prevalence of both primary and the secondary tetracycline resistance in the study cohort. In contrast, the prevalence of metronidazole resistance was considered high with no significant difference between the two resistance groups. H. pylori showed an increased prevalence of resistance to all four of the commonly used therapeutic agents. Thus, eradication therapy should be based on the regional results of susceptibility testing. Moreover, treatment tailored according to individually determined H. pylori susceptibility may be a reasonable future goal.

Meta-analysis of three-in-one single capsule bismuth-containing quadruple therapy for the eradication of Helicobacter pylori

BACKGROUND

Bismuth-containing quadruple therapy has been suggested as first-line and rescue alternative for Helicobacter pylori eradication. Our objective was to perform a meta-analysis evaluating the efficacy and safety of single capsule Pylera^® (bismuth, metronidazole, and tetracycline) plus a proton-pump inhibitor (PPI) in any line of treatment.

METHODS

Studies were selected up to October 2018. Outcomes were eradication and adverse events (AEs) rates pooled using the generic inverse variance method.

RESULTS

In total, 30 studies (6482 patients) were included in the systematic review. The intention-to-treat (ITT) efficacy was 90% (95% CI: 87%-92%, 21 studies, I²  = 88%) in first-line therapy, 89% (95% CI: 86%-93%, 12 studies, I²  = 78%) in second-line and 82% (95% CI: 78%-87%, nine studies, I²  = 60%) in third-line; with no differences by the type or dosage of PPI used. For metronidazole-resistant infection, the ITT efficacy as first-line therapy was 93% (95% CI: 90%-96%, six studies, I²  = 0%). In second-line therapies where patients had been previously treated with clarithromycin, the ITT efficacy was 90% (95% CI: 87%-93%, 11 studies, I²  = 78%). The overall incidence of AEs was 43% (95% CI: 35%-50%, 24 studies, I²  = 92%) and they were mostly mild. In nearly 3% of the cases, treatment was interrupted due to AEs.

CONCLUSIONS

A 10-day treatment with Pylera^® achieved an effective eradication rate of approximately 90% both in first- and second-line therapy. This applies regardless of the type and dose of the PPI, in patients with clarithromycin- or metronidazole-resistant strains, and in those previously treated with clarithromycin.

Treatment of Helicobacter pylori infection in 2018

Treatment options for the eradication of Helicobacter pylori continue to evolve. There have been many guidelines for H. pylori treatment published, which may lead to some confusion. However, most are in agreement with the most recent iteration of the Maastricht treatment guidelines. Triple therapy is still the most frequently used treatment, especially in areas of low clarithromycin resistance. Its best results are achieved when taken for a minimum of 10 days and with high-dose acid suppression. Quadruple therapy is gaining in popularity particularly in areas with increasing resistance to standard triple therapy. Whether three antibiotics, or bismuth and two antibiotics are used, excellent eradication rates are achieved, albeit with increased side effects. Levofloxacin second-line therapy is widely used; however bismuth, when available, is an increasingly successful option. Sequential therapy is challenging in terms of compliance and is no longer recommended. This past year witnessed a notable increase in the number of studies based on antimicrobial susceptibility testing and tailored eradication therapy, reflecting the role of culture-guided treatment, which may well represent the future of H. pylori treatment and prevent the inappropriate use of antibiotics.