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Ishibashi F, Suzuki S, Nagai M, Mochida K, Morishita T. Optimizing Helicobacter pylori Treatment: An Updated Review of Empirical and Susceptibility Test-Based Treatments. Gut Liver 2023; 17:684-697. [PMID: 36843419 PMCID: PMC10502504 DOI: 10.5009/gnl220429] [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: 10/04/2022] [Revised: 11/07/2022] [Accepted: 11/20/2022] [Indexed: 02/28/2023] Open
Abstract
As the rate of discovery of drug-resistant Helicobacter pylori cases increases worldwide, the relevant societies have updated their guidelines for primary eradication regimens. A promising strategy against drug-resistant H. pylori is tailored therapy based on the results of an antibiotic susceptibility test; however, it is difficult to apply this strategy to all cases. Although culture-based antibiotic susceptibility tests can assess resistance to any antimicrobial agent, their greatest disadvantage is the time required to draw a conclusion. In contrast, molecular-based methods, such as polymerase chain reaction, can rapidly determine the presence of resistance, although a single test can only test for one type of antimicrobial agent. Additionally, the limited availability of facilities for molecular-based methods has hindered their widespread use. Therefore, low-cost, minimally invasive, simple, and effective primary regimens are needed. Several studies have compared the efficacy of the latest primary eradication regimens against that of tailored therapies, and their results have shaped guidelines. This article reviews the latest research on empirical and tailored treatments for H. pylori infections. Evidence for the superiority of tailored therapy over empirical therapy is still limited and varies by region and treatment regimen. A network meta-analysis comparing different empirical treatment regimens showed that vonoprazan triple therapy provides a superior eradication effect. Recently, favorable results towards vonoprazan dual therapy have been reported, as it reached eradication levels similar to those of vonoprazan triple therapy. Both vonoprazan dual therapy and tailored therapy based on antibiotic susceptibility tests could contribute to future treatment strategies.
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Affiliation(s)
- Fumiaki Ishibashi
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Ichikawa, Japan
| | - Sho Suzuki
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Ichikawa, Japan
| | - Mizuki Nagai
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Ichikawa, Japan
| | - Kentaro Mochida
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Ichikawa, Japan
| | - Tetsuo Morishita
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Ichikawa, Japan
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2
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García-Morales N, Pérez-Aísa Á, Fiorini G, Tepes B, Castro-Fernández M, Lucendo A, Voynovan I, Bujanda L, Garre A, Rodrigo L, Martínez Domínguez SJ, Denkovski M, Huguet Malavés JM, Jonaitis L, Bumane R, Zaytsev O, Mata Romero P, Barrio J, Fernández-Salazar L, Sarsenbaeva AS, Ortiz Polo I, Alekseenko S, Saracino IM, Vaira D, Keco-Huerga A, Bordin D, Gasbarrini A, Lerang F, Rokkas T, Kupčinskas J, Leja M, Babayeva G, Marcos Pinto R, Tonkić A, Smith S, Phull P, Buzas GM, Simsek H, Boltin D, Gridnyev O, Venerito M, Milivojevic V, Torà N, Cano-Català A, Moreira L, Nyssen OP, Mégraud F, O'Morain C, Gisbert JP, Puig I. Helicobacter pylori Diagnostic Tests Used in Europe: Results of over 34,000 Patients from the European Registry on Helicobacter pylori Management. J Clin Med 2023; 12:4363. [PMID: 37445399 DOI: 10.3390/jcm12134363] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND AND AIMS Several methods are available to diagnose Helicobacter pylori infection. Our objective was to evaluate the tests used for both the initial diagnosis and the confirmation of eradication after treatment in Europe. METHODS The European Registry on the management of Helicobacter pylori infection is an international, multicentre, prospective, non-interventional registry aiming to evaluate the management of Helicobacter pylori-infected patients in Europe. Countries with at least 100 cases registered from June 2013 to April 2021, and with a validated diagnostic method were analysed. Data were quality reviewed. RESULTS A total of 34,920 adult patients from 20 countries were included (mean age 51 years; 61% women). To establish the initial diagnosis, invasive tests were performed in 19,801 (71%) patients, non-invasive in 11,369 (41%), and both in 3437 (12%). The most frequent were histology (n = 11,885; 43%), a rapid urease test (n = 10,636; 38%) and an urea breath test (n = 7577; 27%). According to the age, invasive tests were indicated in 11,179 (77%) ≥50 years, and in 8603 (65%) <50 years. Depending on the country, the use of invasive tests ranged from 29-99% in <50 years to 60-99% in ≥50. Most of the tests used to confirm eradication were non-invasive (n = 32,540; 93%), with the urea breath test being the most frequent (n = 32,540; 78%). In 2983 (9%) post-treatment tests, histology (n = 1887; 5%) or a rapid urease test (n = 1223; 4%) were performed. CONCLUSION A great heterogeneity was observed for the initial diagnosis and confirmation of the eradication. The reasons for the apparent lack of adherence to the clinical guidelines should be further explored.
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Affiliation(s)
- Natalia García-Morales
- Digestive Service, Complexo Hospitalario Universitario de Vigo, Sergas, South Galicia Health Research Institute, 36312 Vigo, Spain
| | - Ángeles Pérez-Aísa
- Unidad de Digestivo, Hospital Costa del Sol Marbella, Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), 29603 Marbella, Spain
| | - Giulia Fiorini
- Department of Surgical and Medical Sciences, IRCCS AOU S. Orsola, 39015 Bologna, Italy
| | - Bojan Tepes
- AM DC Rogaska, 3250 Rogaska Slatina, Slovenia
| | | | | | - Irina Voynovan
- A.S. Loginov, Clinical Scientific Centre, 111123 Moscow, Russia
| | - Luis Bujanda
- Department of Gastroenterology, Biodonostia Health Research Institute, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universidad del País Vasco (UPV/EHU), 20014 San Sebastián, Spain
| | - Ana Garre
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28006 Madrid, Spain
| | - Luis Rodrigo
- Hospital Central de Asturias, 33011 Oviedo, Spain
| | - Samuel Jesús Martínez Domínguez
- Hospital Clínico Lozano Blesa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 50009 Zaragoza, Spain
| | | | | | - Laimas Jonaitis
- Department of Gastroenterology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Renate Bumane
- Digestive Diseases Centre GASTRO, LV-1006 Riga, Latvia
| | - Oleg Zaytsev
- First Clinical Medical Centre, 601900 Kovrov, Russia
| | | | | | | | | | | | | | - Ilaria Maria Saracino
- Department of Surgical and Medical Sciences, IRCCS AOU S. Orsola, 39015 Bologna, Italy
| | - Dino Vaira
- Department of Surgical and Medical Sciences, IRCCS AOU S. Orsola, 39015 Bologna, Italy
| | | | - Dmitry Bordin
- Gastroenterology Unit, A.S. Loginov Moscow Clinical Scientific Center, 111123 Moscow, Russia
- Gastroenterology Unit, Department of Outpatient Therapy and Family Medicine, Tver State Medical University, 170100 Tver, Russia
- Gastroenterology Unit, Department of Propaedeutic of Internal and Gastroenterology, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, 127473 Moscow, Russia
| | - Antonio Gasbarrini
- Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Frode Lerang
- Central Hospital of Ostfold, 1601 Fredrikstad, Norway
| | | | - Juozas Kupčinskas
- Department of Gastroenterology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Marcis Leja
- Digestive Diseases Centre GASTRO, LV-1006 Riga, Latvia
| | | | | | - Ante Tonkić
- Department Gastroenterol & Hepatol, University Hospital Centre Split, 2100 Split, Croatia
| | | | | | - Gyorgy M Buzas
- Gastroenterology, Ferencváros Health Centre, Mester utca 45, 1095 Budapest, Hungary
| | - Halis Simsek
- Internal Med Gastroenterol Department, Hacettepe University School of Medicine, 06230 Ankara, Turkey
| | - Doron Boltin
- Division of Gastroenterology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 4941492, Israel
| | - Oleksiy Gridnyev
- L.T. Malaya Therapy National Institute of the National Academy of Medical Sciences, ID 70483 Kharkiv, Ukraine
| | - Marino Venerito
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, 44, 39120 Magdeburg, Germany
| | | | - Núria Torà
- GOES Research Group, Unitat de Recerca i Innovació, Athaia Xarxa Assistencial Universitària de Manresa, 08243 Manresa, Spain
| | - Anna Cano-Català
- GOES Research Group, Unitat de Recerca i Innovació, Athaia Xarxa Assistencial Universitària de Manresa, 08243 Manresa, Spain
| | - Leticia Moreira
- Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERed), 08036 Barcelona, Spain
| | - Olga P Nyssen
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28006 Madrid, Spain
| | - Francis Mégraud
- INSERM U1312, Université de Bordeaux, 33000 Bordeaux, France
| | - Colm O'Morain
- Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
| | - Javier P Gisbert
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28006 Madrid, Spain
| | - Ignasi Puig
- Althaia Xarxa Assistencial Universitària de Manresa and Universitat de Vic-Universitat Central de Catalunya (UVicUCC), 08242 Manresa, Spain
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García-Morales N, Pérez-Aísa Á, Fiorini G, Tepes B, Castro-Fernández M, Lucendo A, Voynovan I, Bujanda L, Garre A, Rodrigo L, Martínez Domínguez SJ, Denkovski M, Huguet Malavés JM, Jonaitis L, Bumane R, Zaytsev O, Mata Romero P, Barrio J, Fernández-Salazar L, Sarsenbaeva AS, Ortiz Polo I, Alekseenko S, Saracino IM, Vaira D, Keco-Huerga A, Bordin D, Gasbarrini A, Lerang F, Rokkas T, Kupčinskas J, Leja M, Babayeva G, Marcos Pinto R, Tonkić A, Smith S, Phull P, Buzas GM, Simsek H, Boltin D, Gridnyev O, Venerito M, Milivojevic V, Torà N, Cano-Català A, Moreira L, Nyssen OP, Mégraud F, O’Morain C, Gisbert JP, Puig I. Helicobacter pylori Diagnostic Tests Used in Europe: Results of over 34,000 Patients from the European Registry on Helicobacter pylori Management. J Clin Med 2023; 12:4363. [DOI: https:/doi.org/10.3390/jcm12134363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
Background and aims: Several methods are available to diagnose Helicobacter pylori infection. Our objective was to evaluate the tests used for both the initial diagnosis and the confirmation of eradication after treatment in Europe. Methods: The European Registry on the management of Helicobacter pylori infection is an international, multicentre, prospective, non-interventional registry aiming to evaluate the management of Helicobacter pylori-infected patients in Europe. Countries with at least 100 cases registered from June 2013 to April 2021, and with a validated diagnostic method were analysed. Data were quality reviewed. Results: A total of 34,920 adult patients from 20 countries were included (mean age 51 years; 61% women). To establish the initial diagnosis, invasive tests were performed in 19,801 (71%) patients, non-invasive in 11,369 (41%), and both in 3437 (12%). The most frequent were histology (n = 11,885; 43%), a rapid urease test (n = 10,636; 38%) and an urea breath test (n = 7577; 27%). According to the age, invasive tests were indicated in 11,179 (77%) ≥50 years, and in 8603 (65%) <50 years. Depending on the country, the use of invasive tests ranged from 29–99% in <50 years to 60–99% in ≥50. Most of the tests used to confirm eradication were non-invasive (n = 32,540; 93%), with the urea breath test being the most frequent (n = 32,540; 78%). In 2983 (9%) post-treatment tests, histology (n = 1887; 5%) or a rapid urease test (n = 1223; 4%) were performed. Conclusion: A great heterogeneity was observed for the initial diagnosis and confirmation of the eradication. The reasons for the apparent lack of adherence to the clinical guidelines should be further explored.
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Affiliation(s)
- Natalia García-Morales
- Digestive Service, Complexo Hospitalario Universitario de Vigo, Sergas, South Galicia Health Research Institute, 36312 Vigo, Spain
| | - Ángeles Pérez-Aísa
- Unidad de Digestivo, Hospital Costa del Sol Marbella, Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), 29603 Marbella, Spain
| | - Giulia Fiorini
- Department of Surgical and Medical Sciences, IRCCS AOU S. Orsola, 39015 Bologna, Italy
| | - Bojan Tepes
- AM DC Rogaska, 3250 Rogaska Slatina, Slovenia
| | | | | | - Irina Voynovan
- A.S. Loginov, Clinical Scientific Centre, 111123 Moscow, Russia
| | - Luis Bujanda
- Department of Gastroenterology, Biodonostia Health Research Institute, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universidad del País Vasco (UPV/EHU), 20014 San Sebastián, Spain
| | - Ana Garre
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28006 Madrid, Spain
| | - Luis Rodrigo
- Hospital Central de Asturias, 33011 Oviedo, Spain
| | - Samuel Jesús Martínez Domínguez
- Hospital Clínico Lozano Blesa, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 50009 Zaragoza, Spain
| | | | | | - Laimas Jonaitis
- Department of Gastroenterology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Renate Bumane
- Digestive Diseases Centre GASTRO, LV-1006 Riga, Latvia
| | - Oleg Zaytsev
- First Clinical Medical Centre, 601900 Kovrov, Russia
| | | | | | | | | | | | | | - Ilaria Maria Saracino
- Department of Surgical and Medical Sciences, IRCCS AOU S. Orsola, 39015 Bologna, Italy
| | - Dino Vaira
- Department of Surgical and Medical Sciences, IRCCS AOU S. Orsola, 39015 Bologna, Italy
| | | | - Dmitry Bordin
- Gastroenterology Unit, A.S. Loginov Moscow Clinical Scientific Center, 111123 Moscow, Russia
- Gastroenterology Unit, Department of Outpatient Therapy and Family Medicine, Tver State Medical University, 170100 Tver, Russia
- Gastroenterology Unit, Department of Propaedeutic of Internal and Gastroenterology, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, 127473 Moscow, Russia
| | - Antonio Gasbarrini
- Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Frode Lerang
- Central Hospital of Ostfold, 1601 Fredrikstad, Norway
| | | | - Juozas Kupčinskas
- Department of Gastroenterology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Marcis Leja
- Digestive Diseases Centre GASTRO, LV-1006 Riga, Latvia
| | | | | | - Ante Tonkić
- Department Gastroenterol & Hepatol, University Hospital Centre Split, 2100 Split, Croatia
| | | | | | - Gyorgy M. Buzas
- Gastroenterology, Ferencváros Health Centre, Mester utca 45, 1095 Budapest, Hungary
| | - Halis Simsek
- Internal Med Gastroenterol Department, Hacettepe University School of Medicine, 06230 Ankara, Turkey
| | - Doron Boltin
- Division of Gastroenterology, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv 4941492, Israel
| | - Oleksiy Gridnyev
- L.T. Malaya Therapy National Institute of the National Academy of Medical Sciences, ID 70483 Kharkiv, Ukraine
| | - Marino Venerito
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital, 44, 39120 Magdeburg, Germany
| | | | - Núria Torà
- GOES Research Group, Unitat de Recerca i Innovació, Athaia Xarxa Assistencial Universitària de Manresa, 08243 Manresa, Spain
| | - Anna Cano-Català
- GOES Research Group, Unitat de Recerca i Innovació, Athaia Xarxa Assistencial Universitària de Manresa, 08243 Manresa, Spain
| | - Leticia Moreira
- Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERed), 08036 Barcelona, Spain
| | - Olga P. Nyssen
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28006 Madrid, Spain
| | - Francis Mégraud
- INSERM U1312, Université de Bordeaux, 33000 Bordeaux, France
| | - Colm O’Morain
- Rabin Medical Center, Beilinson Campus, Petah Tikva 49100, Israel
| | - Javier P. Gisbert
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28006 Madrid, Spain
| | - Ignasi Puig
- Althaia Xarxa Assistencial Universitària de Manresa and Universitat de Vic-Universitat Central de Catalunya (UVicUCC), 08242 Manresa, Spain
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Srisuphanunt M, Wilairatana P, Kooltheat N, Duangchan T, Katzenmeier G, Rose JB. Molecular Mechanisms of Antibiotic Resistance and Novel Treatment Strategies for Helicobacter pylori Infections. Trop Med Infect Dis 2023; 8:163. [PMID: 36977164 PMCID: PMC10057134 DOI: 10.3390/tropicalmed8030163] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/06/2023] [Accepted: 03/06/2023] [Indexed: 03/18/2023] Open
Abstract
Helicobacter pylori infects approximately 50% of the world's population and is considered the major etiological agent of severe gastric diseases, such as peptic ulcers and gastric carcinoma. Increasing resistance to standard antibiotics has now led to an ever-decreasing efficacy of eradication therapies and the development of novel and improved regimens for treatment is urgently required. Substantial progress has been made over the past few years in the identification of molecular mechanisms which are conducive to resistant phenotypes as well as for efficient strategies to counteract strain resistance and to avoid the use of ineffective antibiotics. These involve molecular testing methods, improved salvage therapies, and the discovery of novel and potent antimicrobial compounds. High rates of prevalence and gastric cancer are currently observed in Asian countries, including Japan, China, Korea, and Taiwan, where concomitantly intensive research efforts were initiated to explore advanced eradication regimens aimed at reducing the risk of gastric cancer. In this review, we present an overview of the known molecular mechanisms of antibiotic resistance and discuss recent intervention strategies for H. pylori diseases, with a view of the research progress in Asian countries.
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Affiliation(s)
- Mayuna Srisuphanunt
- Department of Medical Technology, School of Allied Health Sciences, Walailak University, Nakhon Si Thammarat 80160, Thailand
- Excellent Center for Dengue and Community Public Health, School of Public Health, Walailak University, Nakhon Si Thammarat 80160, Thailand
| | - Polrat Wilairatana
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Nateelak Kooltheat
- Department of Medical Technology, School of Allied Health Sciences, Walailak University, Nakhon Si Thammarat 80160, Thailand
- Hematology and Transfusion Science Research Center, School of Allied Health Sciences, Walailak University, Nakhon Si Thammarat 80160, Thailand
| | - Thitinat Duangchan
- Department of Medical Technology, School of Allied Health Sciences, Walailak University, Nakhon Si Thammarat 80160, Thailand
- Hematology and Transfusion Science Research Center, School of Allied Health Sciences, Walailak University, Nakhon Si Thammarat 80160, Thailand
| | - Gerd Katzenmeier
- Akkhraratchakumari Veterinary College, Walailak University, Nakhon Si Thammarat 80160, Thailand
| | - Joan B. Rose
- Department of Fisheries and Wildlife, Michigan State University, East Lansing, MI 48823, USA
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Rates of Antimicrobial Resistance in Helicobacter pylori Isolates From Clinical Trial Patients Across the US and Europe. Am J Gastroenterol 2023; 118:269-275. [PMID: 36191284 PMCID: PMC9889195 DOI: 10.14309/ajg.0000000000002045] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/26/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Guidelines recommend that proton pump inhibitor-based triple regimens with clarithromycin not be used for Helicobacter pylori infection in areas where clarithromycin resistance is ≥15%, or in patients with prior macrolide use. Up-to-date information on local resistance patterns is limited, especially in the US. Here, we report resistance rates to antibiotics commonly used to treat H. pylori from a large study conducted in the US and Europe (pHalcon-HP). METHODS Gastric mucosal biopsies were collected from adult participants with H. pylori infection during screening. Minimum inhibitory concentrations were determined via agar dilution for clarithromycin, amoxicillin, and metronidazole, with breakpoints ≥1 μg/mL, >0.125 μg/mL, and >8 μg/mL, respectively. Resistance rates were obtained for the US and Europe, and also for US subregions and participating European countries. RESULTS Resistance rates were established in isolates from 907 participants. Overall, 22.2% were resistant to clarithromycin, 1.2% to amoxicillin, and 69.2% to metronidazole. Resistance in the US and Europe was similar; metronidazole resistance was the most prevalent (50%-79%) and amoxicillin the least (≤5%). In all subregions, ≥15% of isolates were resistant to clarithromycin, except the UK (0/8 isolates). Among clarithromycin-resistant isolates, 75% were also metronidazole-resistant. Two US isolates were resistant to clarithromycin and amoxicillin; one of these was also metronidazole-resistant. DISCUSSION The resistance rates observed in this study argue against the continued empiric use of proton pump inhibitor-based triple therapy containing clarithromycin, per treatment guidelines, and highlight the need for antibiotic resistance surveillance and novel treatment strategies for H. pylori infection in the US and Europe.
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Rokkas T, Ekmektzoglou K, Graham DY. Current role of tailored therapy in treating Helicobacter pylori infections. A systematic review, meta-analysis and critical analysis. Helicobacter 2023; 28:e12936. [PMID: 36458328 DOI: 10.1111/hel.12936] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 10/17/2022] [Accepted: 10/21/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND AND AIMS Recent guidelines dictate that all Helicobacter pylori (H. pylori) infected subjects should receive curative therapy. The efficacy of empirical regimens for H. pylori eradication might decline with bacterial, drug, and host factors. The necessity of a tailored therapy still remains controversial. Here we provide a meta-analysis of the current status of susceptibility-based (tailored) therapy in which susceptibility-based therapies were compared to the currently accepted choice of empiric therapy. In this rapidly closing era, neither the susceptibility nor empiric therapies were routinely optimized, such that we report the outcome of comparisons on the efficacy of unoptimized tailored vs. locally preferred empiric treatments. METHODS PubMed, Medline, and Embase databases were searched using suitable keywords. Individual and pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the fixed- or random-effects model as appropriate. Heterogeneity was calculated employing the Cochrane Q test and I2 values, whereas the possibility of publication bias was examined by constructing funnel plots. Additionally, subgroup and sensitivity analyses were performed. RESULTS Thirty-four studies were included with a total of 9613 patients. Tailored therapy proved superior to empiric treatment [OR 2.07 (95% CI 1.53-2.79)]. However, tailored therapy achieved eradication rates >90% in only 15 (44%) studies and >95% in only 6 (17.6%). CONCLUSIONS Although tailored therapy performed better than empiric treatment, the lack of optimization of therapies failed to reliably achieve high cure rates (>90%). These results emphasize that H. pylori infection, like other infectious diseases, should utilize the principles of antimicrobial stewardship in relation to treatment guidance.
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Affiliation(s)
- Theodore Rokkas
- Gastroenterology Clinic, Henry Dunant Hospital, Athens, Greece.,Medical School, European University of Cyprus, Nicosia, Cyprus
| | - Konstantine Ekmektzoglou
- Gastroenterology Clinic, Henry Dunant Hospital, Athens, Greece.,Medical School, European University of Cyprus, Nicosia, Cyprus
| | - David Y Graham
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
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Zhao Z, Zou PY, Su NY, Guo Y, Wang XW, Zhao JT, Mei H, Shi Q, Wang B, Chen DF, Lan CH. High-dose dual therapy versus culture-based susceptibility-guided therapy as a rescue regimen for Helicobacter pylori infection: a randomized controlled trial. Therap Adv Gastroenterol 2022; 15:17562848221145566. [PMID: 36600682 PMCID: PMC9806367 DOI: 10.1177/17562848221145566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/23/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Although the Maastricht VI/Florence consensus report recommended high-dose proton pump inhibitor-amoxicillin dual therapy as possible rescue therapy for Helicobacter pylori infection, clinical evidence of its efficacy was lacking. OBJECTIVES To compare the efficacy, safety, patient compliance, and cost between high-dose dual therapy (HDDT) and culture-based susceptibility-guided therapy (CB-SGT) as a rescue regimen for H. pylori infection. DESIGN A single-center, open-label, randomized controlled clinical trial. METHODS In all, 146 patients with a history of eradication failure were enrolled and randomly assigned to receive HDDT or CB-SGT. HDDT consisted of esomeprazole 20 mg and amoxicillin 750 mg, both given four times per day (qid). CB-SGT consisted of esomeprazole 20 mg twice daily (bid), amoxicillin 1000 mg bid plus clarithromycin 500 mg bid, metronidazole 400 mg bid, or levofloxacin 500 mg daily (qd) for sensitive patients, in that order. For patients with triple resistance, a bismuth-containing regimen with a high dose of metronidazole was chosen, including esomeprazole 20 mg bid, bismuth 220 mg bid, amoxicillin 1000 mg bid, and metronidazole 400 mg qid. All regimens were given for 14 days. RESULTS The eradication H. pylori rates achieved with HDDT in the intention-to-treat (ITT), per-protocol, and modified ITT analyses were all 84.9% [62/73, 95% confidence interval (CI): 76.5-93.9%], compared with 83.6% (61/73, 95% CI: 74.9-92.3%), 84.7% (61/72, 95% CI: 76.2-93.2%), and 84.7% (61/72, 95% CI: 76.2-93.2%) with CB-SGT, respectively. For patients with CYP2C19 polymorphisms of intermediate/poor metabolizers, the eradication rates of HDDT and CB-SGT were 90.70% (39/43, 95% CI: 77.86-97.41%) and 84.21% (32/38, 95% CI: 68.75-93.98%), respectively. The difference between groups was 6.49% (95% CI: -8.00% to 20.97%), and the non-inferiority p value was 0.0128. For patients with a treatment interval of more than 3 months, the eradication rates of the two regimens reached 88.71% (95% CI: 78.11-95.34%) and 71.97% (95% CI: 70.02-90.64%). The difference between groups was 6.74% (95% CI: -5.71% to 19.20%), with a non-inferiority p value of 0.0042. Patient adherence was high in both groups. The HDDT had a lower cost and rate of side effects (p < 0.001) compared with CB-SGT. CONCLUSIONS HDDT can reach an eradication rate of 85% in treatment-experienced patients of H. pylori infection and 91% in patients with CYP2C19 polymorphisms of intermediate/poor metabolizers, with good compliance, lower side effects and costs, and less use of antibiotics. In conclusion, HDDT offers an effective rescue regimen for H. pylori infection. REGISTRATION This clinical trial was registered at the Chinese Clinical Trail Registry (trail registration number: ChiCTR1900025044).
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Affiliation(s)
| | | | | | - Yan Guo
- Department of Gastroenterology, Chongqing Key
Laboratory of Digestive Malignancies, Daping Hospital, Army Medical
University (Third Military Medical University), Chongqing, P.R. China
| | - Xing-Wei Wang
- Department of Gastroenterology, Chongqing Key
Laboratory of Digestive Malignancies, Daping Hospital, Army Medical
University (Third Military Medical University), Chongqing, P.R. China
| | - Jing-Tao Zhao
- Department of Gastroenterology, Chongqing Key
Laboratory of Digestive Malignancies, Daping Hospital, Army Medical
University (Third Military Medical University), Chongqing, P.R. China
| | - Hao Mei
- Department of Gastroenterology, Chongqing Key
Laboratory of Digestive Malignancies, Daping Hospital, Army Medical
University (Third Military Medical University), Chongqing, P.R. China
| | - Qing Shi
- Department of Gastroenterology, Chongqing Key
Laboratory of Digestive Malignancies, Daping Hospital, Army Medical
University (Third Military Medical University), Chongqing, P.R. China
| | - Bin Wang
- Department of Gastroenterology, Chongqing Key
Laboratory of Digestive Malignancies, Daping Hospital, Army Medical
University (Third Military Medical University), Chongqing 400042, P.R.
China
| | - Dong-Feng Chen
- Department of Gastroenterology, Chongqing Key
Laboratory of Digestive Malignancies, Daping Hospital, Army Medical
University (Third Military Medical University), Chongqing 400042, P.R.
China
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8
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Ma Q, Li H, Liao J, Cai Z, Zhang B. Tailored therapy for Helicobacter pylori eradication: A systematic review and meta-analysis. Front Pharmacol 2022; 13:908202. [PMID: 36160444 PMCID: PMC9495299 DOI: 10.3389/fphar.2022.908202] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Due to an increase in drug resistance, the eradication rate of H. pylori with empirical therapy has declined. Tailored therapy has been proposed as an alternative to standard empirical treatments. The necessity of personalized eradication therapy remains unclear. The aim of this study was to determine whether tailored therapy is superior to empirical therapy for H. pylori infection. Methods: We searched for eligible randomized controlled trials in the PubMed, Embase (Ovid), Wanfang, and Cochrane Central Register of Controlled Trials databases up to 10 December 2021. A random effects model comparing pooled relative risks (RRs) with 95% confidence intervals (CIs) was applied in the meta-analysis. Results: Twenty-one studies were included in the meta-analysis. In the first-line treatment, tailored therapy was more effective than empirical therapy (RR, 1.14 [95% CI, 1.08–1.21], I2 = 72.2%). In the second-line therapy setting, the results did not reveal significant differences between the two treatments (RR, 1.05 [95% CI, 0.84–1.30], I2 = 80.6%). A similar result was observed in mixed second- and third-line treatments (RR, 1.03 [95% CI, 0.96–1.11], I2 = 0.0%). Regarding adverse events, no significant differences were found between the two treatments (RR, 0.90 [95% CI, 0.80–1.01], I2 = 35.7%). Most of the results were highly heterogeneous. Conclusion: A tailored approach might provide a better eradication rate than empirical methods in first-line treatment. There might be no obvious advantage in second-line or mixed second- and third-line treatments third-line treatment. Due to the high heterogeneity, the results should be interpreted with caution. Further clinical studies are needed and justified.
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Affiliation(s)
- Qin Ma
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hancong Li
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Liao
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
- West China School of Nursing, Sichuan University, Chengdu, China
| | - Zhaolun Cai
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Bo Zhang, ; Zhaolun Cai,
| | - Bo Zhang
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Bo Zhang, ; Zhaolun Cai,
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9
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Nyssen OP, Espada M, Gisbert JP. Empirical vs. Susceptibility-Guided Treatment of Helicobacter pylori Infection: A Systematic Review and Meta-Analysis. Front Microbiol 2022; 13:913436. [PMID: 35774456 PMCID: PMC9237546 DOI: 10.3389/fmicb.2022.913436] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/17/2022] [Indexed: 01/30/2023] Open
Abstract
Background Treating Helicobacter pylori infection according to antibiotic resistance has been frequently recommended. However, information on its real effectiveness is scarce. Aim The aim of this study is to perform a meta-analysis comparing empirical vs. susceptibility-guided treatment of H. pylori. Methods Selection of studies: Studies comparing empirical versus susceptibility-guided treatment were selected. Search strategy: electronic and manual up to August 2021. Data synthesis: by intention-to-treat (random-effects model). Results Overall, 54 studies were included (6,705 patients in the susceptibility-guided group and 7,895 in the empirical group). H. pylori eradication rate was 86 vs. 76%, respectively (RR: 1.12; 95% CI: 1.08-1.17; I 2: 83%). Similar results were found when only RCTs were evaluated (24 studies; RR: 1.16; 95% CI: 1.11-1.22; I 2: 71%) and when susceptibility testing was assessed by culture (RR: 1.12; 95% CI: 1.06-1.18) or PCR (RR: 1.14; 95% CI: 1.05-1.23). For first-line treatments (naïve patients; 30 studies), better efficacy results were obtained with the susceptibility-guided strategy (RR: 1.15; 95% CI: 1.11-1.20; I 2: 79%). However, for empirical first-line quadruple regimens, in particular (both with and without bismuth, excluding the suboptimal triple therapies), not based on CYP2C19 gene polymorphism, no differences in efficacy were found compared with the susceptibility-guided group (RR: 1.04; 95% CI: 0.99-1.09); this lack of difference was confirmed in RCTs (RR: 1.05; 95% CI: 0.99-1.12). For rescue therapies (13 studies, most 2nd-line), similar results were demonstrated for both strategies, including all studies (RR: 1.09; 95% CI: 0.97-1.22; I 2: 82%) and when only RCTs were considered (RR: 1.15; 95% CI: 0.97-1.36). Conclusion The benefit of susceptibility-guided treatment over empirical treatment of H. pylori infection could not be demonstrated, either in first-line (if the most updated quadruple regimens are prescribed) or in rescue therapies.
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Affiliation(s)
- Olga P. Nyssen
- Gastroenterology Unit, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Hospital Universitario de La Princesa, Madrid, Spain
- Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Marta Espada
- Gastroenterology Unit, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Hospital Universitario de La Princesa, Madrid, Spain
- Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Javier P. Gisbert
- Gastroenterology Unit, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Hospital Universitario de La Princesa, Madrid, Spain
- Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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10
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Zagari RM, Romano M, Frazzoni L, Marasco G, Dajti E, Arcidiacono PG, Armuzzi A, Biagi F, Cannizzaro R, Cavestro GM, Ciacci C, Monica F, Peralta S, Radaelli F, Bazzoli F. Adherence to international guidelines for the management of Helicobacter pylori infection among gastroenterologists and gastroenterology fellows in Italy: A Survey of the Italian Federation of Digestive Diseases - FISMAD. Helicobacter 2022; 27:e12862. [PMID: 34766392 PMCID: PMC9286052 DOI: 10.1111/hel.12862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/18/2021] [Accepted: 09/23/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Information on the management of Helicobacter (H.) pylori infection by gastroenterologists and gastroenterology fellows are scarce. We aimed to assess practice of gastroenterologists and gastroenterology fellows and their adherence to guidelines for diagnosis and treatment of H. pylori infection in Italy. MATERIALS AND METHODS All gastroenterologists and gastroenterology fellows attending the National Congress of Digestive Diseases - FISMAD were invited to fill-in an on-line questionnaire. The questionnaire included questions on the diagnosis and treatment of H. pylori infection. RESULTS A total of 279 gastroenterologists and 61 gastroenterology fellows participated to the study. The 13 C-urea breath test was the most preferred method among gastroenterologists and fellows for the diagnosis of H. pylori infection (40.4% and 57.6%, respectively) and the confirmation of eradication (61.3% and 70%, respectively). Sequential therapy was the most preferred first-line treatment of H. pylori for both gastroenterologists and gastroenterology fellows (31.8% and 44%, respectively), followed by bismuth quadruple therapy (31% and 27.6%, respectively) and clarithromycin triple therapy (26.8% and 22.4%, respectively). Only 30% of gastroenterologists and 38.5% of fellows used the clarithromycin triple therapy for the recommended duration of 14 days. Bismuth quadruple therapy was the most preferred second-line therapy for both gastroenterologists and fellows. The majority of gastroenterologists and fellows would prefer an empirical therapy at third line (72.6% and 62.5%, respectively) and a susceptibility-guided therapy at fourth line (46.7% and 71.4%, respectively). CONCLUSIONS Practices of gastroenterologists and gastroenterology fellows are in line with guidelines' recommendations, apart for the first-line treatment of H. pylori infection. Targeted educational interventions to improve adherence to guidelines are needed.
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Affiliation(s)
- Rocco Maurizio Zagari
- Gastroenterology UnitIRCCS Azienda Ospedaliero‐Universitaria, S. Orsola HospitalBolognaItaly
- Department of Medical and Surgical SciencesUniversity of BolognaItaly
| | - Marco Romano
- Division of HepatogastroenterologyDepartment of Precision MedicineUniversity of Campania "Luigi Vanvitelli"NaplesItaly
| | - Leonardo Frazzoni
- Gastroenterology UnitIRCCS Azienda Ospedaliero‐Universitaria, S. Orsola HospitalBolognaItaly
- Department of Medical and Surgical SciencesUniversity of BolognaItaly
| | - Giovanni Marasco
- Department of Medical and Surgical SciencesUniversity of BolognaItaly
| | - Elton Dajti
- Gastroenterology UnitIRCCS Azienda Ospedaliero‐Universitaria, S. Orsola HospitalBolognaItaly
- Department of Medical and Surgical SciencesUniversity of BolognaItaly
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography DivisionIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Alessandro Armuzzi
- Department of Medical and Surgical SciencesIRCCS A. Gemelli University HospitalRomeItaly
| | - Federico Biagi
- Gastroenterology UnitIRCCS Istituti Clinici Scientifici MaugeriUniversity of PaviaItaly
| | - Renato Cannizzaro
- Centro Riferimento Oncologico IRCCSIstituto Nazionale TumoriAvianoItaly
| | - Giulia Martina Cavestro
- Gastroenterology and Gastrointestinal Endoscopy UnitIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Carolina Ciacci
- Gastrointestinal UnitDepartment of Medicine, Surgery and DentistryUniversity of SalernoItaly
| | - Fabio Monica
- Gastroenterology and Digestive Endoscopy‘Cattinara’ Academic HospitalTriesteItaly
| | - Sergio Peralta
- Gastroenterology and Hepatology UnitUniversity of PalermoItaly
| | | | - Franco Bazzoli
- Gastroenterology UnitIRCCS Azienda Ospedaliero‐Universitaria, S. Orsola HospitalBolognaItaly
- Department of Medical and Surgical SciencesUniversity of BolognaItaly
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11
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Hung CW, Chen SCC, Ku LJE, Sheu BS, Yang YJ. A Culture-Based Strategy Is More Cost Effective Than an Empiric Therapy Strategy in Managing Pediatric Helicobacter pylori Infection. Front Pediatr 2022; 10:860960. [PMID: 35592847 PMCID: PMC9110685 DOI: 10.3389/fped.2022.860960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/13/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Helicobacter pylori infection is a major cause of peptic ulcers and gastric cancer. This study aimed to compare the eradication rate and essential costs of culture-based and empiric therapy strategies in treating pediatric H. pylori infection. METHODS We retrospectively enrolled patients aged <18 years with a diagnosis of H. pylori infection who received esophagogastroduodenoscopy at two medical centers in southern Taiwan from 1998 to 2018. Patients with positive cultures and minimum inhibitory concentration test results were allocated to a culture-based strategy, and those with negative cultures or without culture as an empiric therapy strategy. We collected demographic data and eradication rates, and calculated the total essential costs of treating a hypothetical cohort of 1,000 pediatric patients based on the two strategies. RESULTS Ninety-six patients were enrolled, of whom 55 received a culture-based strategy and 41 received an empiric therapy strategy. The eradication rates with the first treatment were 89.1 and 75.6% in the culture-based and empiric therapy strategy, respectively. There were no significant differences in age, sex, and endoscopic diagnosis between the two strategies. For every 10% increase in those receiving a culture-based strategy, the total cost would have been reduced by US$466 in a hypothetical cohort of 1,000 patients. For every 10% increase in successful eradication rate, the total cost was reduced by US$24,058 with a culture-based strategy and by US$20,241 with an empiric therapy strategy. CONCLUSIONS A culture-based strategy was more cost effective than an empiric therapy strategy in treating pediatric H. pylori-infected patients.
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Affiliation(s)
- Chi-Wen Hung
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Department of Pediatrics and Institute of Clinical Medicine, National Cheng Kung University Hospital, Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Solomon Chih-Chen Chen
- Department of Pediatrics, Taitung Christian Hospital, Taitung, Taiwan.,Department of Medicine, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Medicine, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Li-Jung Elizabeth Ku
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Bor-Shyang Sheu
- Department of Pediatrics and Institute of Clinical Medicine, National Cheng Kung University Hospital, Medical College, National Cheng Kung University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yao-Jong Yang
- Department of Pediatrics and Institute of Clinical Medicine, National Cheng Kung University Hospital, Medical College, National Cheng Kung University, Tainan, Taiwan
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12
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Zurita J, Sevillano G, Paz Y Miño A, Zurita-Salinas C, Peñaherrera V, Echeverría M, Navarrete H. Mutations associated with Helicobacter pylori antimicrobial resistance in the Ecuadorian population. J Appl Microbiol 2021; 132:2694-2704. [PMID: 34856035 DOI: 10.1111/jam.15396] [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: 04/15/2021] [Revised: 11/19/2021] [Accepted: 11/28/2021] [Indexed: 11/30/2022]
Abstract
AIMS We described the presence of Helicobacter pylori (HP) and estimated the prevalence of primary and secondary resistance using molecular detection in gastric biopsies of Ecuadorian patients. METHODS AND RESULTS 66.7% (238/357) of the patients demonstrated the presence of HP using CerTest qPCR. Of these, 69.79% (104/149) were without previous HP eradication treatment and 64.42% (134/208) with prior HP eradication treatment. The mutation-associated resistance rate for clarithromycin was 33.64% (primary resistance) and 32.82% (secondary resistance), whereas that in levofloxacin the primary and secondary resistance was 37.38% and 42%, respectively. For tetracycline and rifabutin, primary and secondary resistance was 0%. Primary and secondary resistance for metronidazole and amoxicillin could not be evaluated by genotypic methods (PCR and sequencing). CONCLUSIONS The analysis of mutations in gyrA, 23S rRNA and 16S rRNA is useful to detect bacterial resistance as a guide for eradication therapy following failure of the first-line regimen. SIGNIFICANCE AND IMPACT OF THE STUDY This study carried out in an Ecuadorian population indicates that the resistance of HP to first-line antibiotics is high, which may contribute to the high rates of treatment failure, and other treatment alternatives should be considered.
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Affiliation(s)
- Jeannete Zurita
- Servicio de Microbiologia y Tuberculosis, Hospital Vozandes, Quito, Ecuador.,Facultad de Medicina, Pontificia Universidad Católica del Ecuador, Quito, Ecuador.,Unidad de Investigaciones en Biomedicina, Zurita & Zurita Laboratorios, Quito, Ecuador
| | - Gabriela Sevillano
- Unidad de Investigaciones en Biomedicina, Zurita & Zurita Laboratorios, Quito, Ecuador
| | - Ariane Paz Y Miño
- Unidad de Investigaciones en Biomedicina, Zurita & Zurita Laboratorios, Quito, Ecuador
| | - Camilo Zurita-Salinas
- Unidad de Investigaciones en Biomedicina, Zurita & Zurita Laboratorios, Quito, Ecuador
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- Servicio de Gastroenterología, Hospital Vozandes, Quito, Ecuador
| | - Hugo Navarrete
- Facultad de Ciencias Exactas y Naturales, Pontificia Universidad Católica del Ecuador, Quito, Ecuador
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13
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Gingold-Belfer R, Niv Y, Schmilovitz-Weiss H, Levi Z, Boltin D. Susceptibility-guided versus empirical treatment for Helicobacter pylori infection: A systematic review and meta-analysis. J Gastroenterol Hepatol 2021; 36:2649-2658. [PMID: 34114673 DOI: 10.1111/jgh.15575] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/10/2021] [Accepted: 06/08/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIM Empirical therapy for Helicobacter pylori infection is limited by increasing antibiotic resistance and suboptimal eradication rates. Studies of the relative effectiveness of susceptibility-guided therapy have produced conflicting results. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine whether susceptibility-guided therapy is superior to empirical therapy for H. pylori infection. METHODS We searched articles listed in PubMed, MEDLINE, EMBASE, and Web of Science through May 25, 2020, RCTs comparing susceptibility-guided versus empirical therapy for H. pylori infection. Outcomes, including effectiveness and safety, were analyzed in a meta-analysis. RESULTS Our final analysis included 16 studies, comprising 2374 patients who received susceptibility-guided therapy and 2451 patients who received empirical treatment. In previously untreated subjects, susceptibility-guided therapy was slightly more effective than empirical therapy (intent to treat risk ratio [RR], 1.14; 95% confidence interval [CI], 1.07-1.21; P < 0.0001, I2 = 75%). Susceptibility-guided therapy was superior to first-line clarithromycin-based triple therapy only when clarithromycin resistance exceeded 20% (RR, 1.18; 95% CI, 1.07-1.30; P = 0.001, I2 = 81%). Susceptibility-guided therapy was not more effective than empirical quadruple therapy (RR, 1.02; 95% CI, 0.92-1.13; P = 0.759, I2 = 80%). Three RCTs were performed exclusively among previously treated subjects, and were highly heterogeneous. CONCLUSIONS Our findings suggest that susceptibility-guided treatment may be slightly superior to empirical first line triple therapy. Susceptibility- guided treatment does not appear to be superior to empirical first-line quadruple therapy or empirical rescue therapy.
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Affiliation(s)
- Rachel Gingold-Belfer
- Division of Gastroenterology, , Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaron Niv
- Division of Patient Safety and Quality Improvement, Ministry of Health, Jerusalem, Israel
| | - Hemda Schmilovitz-Weiss
- Division of Gastroenterology, , Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zohar Levi
- Division of Gastroenterology, , Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Doron Boltin
- Division of Gastroenterology, , Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Cortés P, Nelson AD, Bi Y, Stancampiano FF, Murray LP, Pujalte GGA, Gomez V, Harris DM. Treatment Approach of Refractory Helicobacter pylori Infection: A Comprehensive Review. J Prim Care Community Health 2021; 12:21501327211014087. [PMID: 33949229 PMCID: PMC8114244 DOI: 10.1177/21501327211014087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
H. pylori is the most common infection in the world and is associated with gastrointestinal and extra-gastrointestinal manifestations, including peptic ulcer disease, gastrointestinal bleeding, and lymphoproliferative disorders. Despite being discovered less than half a century ago, antibiotic resistance, exacerbated by medication non-adherence and inefficacy of proton pump inhibitors, has grown substantially, explaining the rising incidence of refractory H. pylori infection. In this review, we discuss risk factors, treatment options, surveillance and follow-up, as well as emerging therapies for refractory H. pylori.
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Affiliation(s)
| | | | - Yan Bi
- Mayo Clinic, Jacksonville, FL, USA
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15
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Perkovic N, Mestrovic A, Bozic J, Ivelja MP, Vukovic J, Kardum G, Sundov Z, Tonkic M, Puljiz Z, Vukojevic K, Tonkic A. Randomized Clinical Trial Comparing Concomitant and Tailored Therapy for Eradication of Helicobacter pylori Infection. J Pers Med 2021; 11:jpm11060534. [PMID: 34207870 PMCID: PMC8229321 DOI: 10.3390/jpm11060534] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 12/12/2022] Open
Abstract
As high clarithromycin resistance (>20%) in the Split-Dalmatia region of Croatia hinders the treatment of H. pylori infection, the primary objective of this study was to compare concomitant quadruple with the tailored, personalized therapy as first-line eradication treatment of H. pylori. In an open-label, randomized clinical trial, 80 patients with H. pylori infection were randomly assigned to either concomitant (esomeprazole 40 mg, amoxicillin 1 gr, metronidazole 500 mg, clarithromycin 500 mg, twice daily for 14 days) or tailored therapy in accordance with the results of the antimicrobial susceptibility testing. Eradication status was assessed 4 weeks after treatment. Eradication rates were significantly higher in tailored group than in concomitant group both in intention-to-treat (70 vs. 92.5%, p = 0.010) and per-protocol (87.5 vs. 100%, p = 0.030) analysis in the setting of increasing antibiotic resistance (clarithromycin 37.5%, metronidazole 17.5%, dual resistance 10%). Adverse effects were more frequent in the concomitant group (32.5 vs. 7.5%, p = 0.006). Tailored therapy achieves higher eradication with a lower adverse events rate. With the increasing resistance of H. pylori strains to antibiotic treatment, eradication regimes with such characteristics should be strongly considered as a reasonable choice for first-line treatment.
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Affiliation(s)
- Nikola Perkovic
- Department of Gastroenterology, University Hospital of Split, 21000 Split, Croatia; (A.M.); (J.V.); (Z.S.); (Z.P.); (A.T.)
- Correspondence:
| | - Antonio Mestrovic
- Department of Gastroenterology, University Hospital of Split, 21000 Split, Croatia; (A.M.); (J.V.); (Z.S.); (Z.P.); (A.T.)
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia;
| | - Mirela Pavicic Ivelja
- Department for Infectious Diseases, University Hospital of Split, 21000 Split, Croatia;
| | - Jonatan Vukovic
- Department of Gastroenterology, University Hospital of Split, 21000 Split, Croatia; (A.M.); (J.V.); (Z.S.); (Z.P.); (A.T.)
| | - Goran Kardum
- Department of Psychology, Faculty of Humanities and Social Sciences, University of Split, 21000 Split, Croatia;
| | - Zeljko Sundov
- Department of Gastroenterology, University Hospital of Split, 21000 Split, Croatia; (A.M.); (J.V.); (Z.S.); (Z.P.); (A.T.)
- Department of Internal Medicine, University of Split School of Medicine, 21000 Split, Croatia
| | - Marija Tonkic
- Department of Microbiology and Parasitology, University Hospital of Split, 21000 Split, Croatia;
- Department of Medical Microbiology and Parasitology, University of Split School of Medicine, 21000 Split, Croatia
| | - Zeljko Puljiz
- Department of Gastroenterology, University Hospital of Split, 21000 Split, Croatia; (A.M.); (J.V.); (Z.S.); (Z.P.); (A.T.)
- Department of Internal Medicine, University of Split School of Medicine, 21000 Split, Croatia
| | - Katarina Vukojevic
- Department of Anatomy, University of Split School of Medicine, 21000 Split, Croatia;
| | - Ante Tonkic
- Department of Gastroenterology, University Hospital of Split, 21000 Split, Croatia; (A.M.); (J.V.); (Z.S.); (Z.P.); (A.T.)
- Department of Internal Medicine, University of Split School of Medicine, 21000 Split, Croatia
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Park H, Lee JH. Recent Trends in Tailored Treatments for Helicobacter pylori Infection. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2021. [DOI: 10.7704/kjhugr.2021.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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17
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Gisbert JP. Empirical or susceptibility-guided treatment for Helicobacter pylori infection? A comprehensive review. Therap Adv Gastroenterol 2020; 13:1756284820968736. [PMID: 33240392 PMCID: PMC7675893 DOI: 10.1177/1756284820968736] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/01/2020] [Indexed: 02/06/2023] Open
Abstract
Although susceptibility-guided therapy is frequently recommended for Helicobacter pylori infection, the evidence available to date supporting this strategy is limited. The aim of the present article is to review the advantages and limitations of the susceptibility-guided and the empirical strategies to treat this infection. We performed a bibliographic search to identify studies investigating H. pylori susceptibility-guided therapy. Culture is not the only way to assess antibiotic resistance, as different polymerase chain reaction-based approaches have been developed as alternative methods. For detecting H. pylori antimicrobial resistance, a molecular approach based on a stool sample might enable more convenient, time-saving methods. Unfortunately, the antimicrobial susceptibility cannot be obtained in all cases. Furthermore, antibiotic susceptibility testing in clinical practice yields useful information only for a few antibiotics: clarithromycin, metronidazole, and quinolones. In addition, susceptibility towards clarithromycin and metronidazole in vitro does not necessarily lead to eradication in vivo. In the case of H. pylori therapy failure, we should not re-administer any of the antibiotics against which H. pylori has probably become resistant. Our updated meta-analysis showed that susceptibility-guided treatment is not better than empirical treatment of H. pylori infection in first-line therapy if the most updated quadruple regimens are empirically prescribed, and similar efficacy results were also demonstrated with the two strategies for second-line therapy. Cumulative H. pylori eradication rate with several successive rescue therapies empirically prescribed reaches almost 100%. Finally, the studies that have evaluated the cost-effectiveness of the susceptibility-guided treatment have achieved contradictory results. In summary, we can conclude that the evidence is too limited to support the generalized use of susceptibility-guided therapy for H. pylori treatment in routine clinical practice, either as first-line or as rescue treatment. Nevertheless, it would be recommended that susceptibility tests are performed routinely, even before prescribing first-line treatment, in specialized centers with an interest in H. pylori management.
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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, Centro de Investigación Biomédica en Red de Enfermedades
Hepáticas y Digestivas (CIBEREHD), Diego de León, 62, Madrid, 28006, Spain
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18
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Efficacy of a tailored PCR-guided triple therapy in the treatment of Helicobacter pylori infection. Med Mal Infect 2019; 50:492-499. [PMID: 31257067 DOI: 10.1016/j.medmal.2019.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/04/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Resistance to clarithromycin and fluoroquinolones is increasing in many countries. We aimed to assess the efficacy of a tailored PCR-guided triple therapy versus an empirical triple therapy in the treatment of H. pylori infection. PATIENTS AND METHODS French multicenter prospective open-label randomized study to assess H. pylori and resistance to clarithromycin and levofloxacin with GenoType HelicoDR® test. Patients of the control group were treated with empirical therapy of proton pump inhibitor (PPI), amoxicillin, and clarithromycin for 7 days. Patients of the experimental group with clarithromycin-susceptible strains, clarithromycin-resistant/levofloxacin-susceptible strains, and with clarithromycin-resistant/levofloxacin-resistant strains received tailored therapy of PPI, amoxicillin, and clarithromycin for 7 days, PPI, amoxicillin, and levofloxacin for 10 days, and PPI, amoxicillin, and metronidazole for 14 days, respectively. H. pylori eradication was assessed by 13C urea breath test at least 28 days after the end of treatment. RESULTS We included 526 patients: 260 (49.4%) were randomly assigned to empirical triple therapy and 266 (50.6%) to tailored therapy. Clarithromycin and levofloxacin resistances were 23.3% and 12.8%, respectively. Follow-up urea breath test was available for 415 (78.9%) patients. Tailored therapy was superior to empirical therapy in terms of eradication (85.5% vs. 73.1%, RR=1.85, 95%CI [1.25-2.78], p=0.003). Findings were consistent in the susceptibility analysis using multiple imputation (RR=1.61, 95%CI [1.14-2.27], P=0.003) and per-protocol analysis (RR=1.89, 95%CI [0.25-2.78], p=0.003). CONCLUSION In a country with a high level of clarithromycin resistance, tailored PCR-guided therapy was superior to empirical triple therapy for H. pylori eradication (https://www.ClinicalTrials.gov: NCT01168063).
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Helicobacter pylori Mutations Detected by Next-Generation Sequencing in Formalin-Fixed, Paraffin-Embedded Gastric Biopsy Specimens Are Associated with Treatment Failure. J Clin Microbiol 2019; 57:JCM.01834-18. [PMID: 31068413 DOI: 10.1128/jcm.01834-18] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 05/02/2019] [Indexed: 12/14/2022] Open
Abstract
Helicobacter pylori antibiotic resistance is widespread and increasing worldwide. Routine detection of H. pylori mutations that invoke antimicrobial resistance may be a useful approach to guide antimicrobial therapy and possibly avert treatment failure. In this study, formalin-fixed, paraffin-embedded (FFPE) gastric biopsy specimens from a cohort of individuals from northern Ohio in the United States were examined using a next-generation sequencing (NGS) assay to detect H. pylori mutations that are known to confer resistance to clarithromycin, levofloxacin, and tetracycline. From January 2016 to January 2017, 133 H. pylori-infected gastric biopsy specimens were identified histologically and subsequently analyzed by NGS to detect mutations in gyrA, 23S rRNA, and 16S rRNA genes. The method successfully detected H. pylori in 126 of 133 cases (95% sensitivity). Mutations conferring resistance were present in 92 cases (73%), including 63 cases with one mutation (50%) and 29 cases with mutations in multiple genes (23%). Treatment outcomes were available in 58 cases. Sixteen of the 58 cases failed therapy (28%). Therapy failure correlated with the number of mutated genes: no failure in cases with no mutations (0/15), 19% (5/27) failure in cases with one gene mutation, and 69% (11/16) failure in cases with more than one mutated gene. Common 23S rRNA mutations (A2142G or A2413G) were present in 88% (14/16) of failed cases as opposed to in only 10% (4/42) of eradicated cases (P < 0.001). This NGS assay can be used on remnant specimens collected during standard-of-care testing to detect mutations that correlate with increased risk of treatment failure. A prospective study is needed to determine if the risk of treatment failure can be decreased by using this assay to guide antibiotic therapy.
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20
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Chen Q, Long X, Ji Y, Liang X, Li D, Gao H, Xu B, Liu M, Chen Y, Sun Y, Zhao Y, Xu G, Song Y, Yu L, Zhang W, Liu W, Graham DY, Lu H. Randomised controlled trial: susceptibility-guided therapy versus empiric bismuth quadruple therapy for first-line Helicobacter pylori treatment. Aliment Pharmacol Ther 2019; 49:1385-1394. [PMID: 31020673 DOI: 10.1111/apt.15273] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/04/2019] [Accepted: 03/29/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Increasing Helicobacter pylori resistance has led to decreases in treatment effectiveness. AIM To test the effectiveness of susceptibility-guided therapy vs a locally highly effective empiric modified bismuth quadruple therapy for first-line H pylori treatment in a region with high antimicrobial resistance. METHODS We compared 14-day susceptibility-guided with empiric therapy using a multicentre superiority-design trial, which randomised H pylori infected subjects 3:1 to (a) susceptibility-guided therapies contained esomeprazole 20 mg and amoxicillin 1 g b.d. plus clarithromycin 500 mg, metronidazole 400 mg b.d., or levofloxacin 500 mg daily for susceptible infections or bismuth 220 mg b.d. and metronidazole 400 mg q.d.s. for triple-resistant infections; (b) Empiric therapy contained esomeprazole 20 mg, bismuth 220 mg b.d., amoxicillin 1 g and metronidazole 400 mg t.d.s. Primary outcome was H pylori eradication. RESULTS Between February 2017 and March 2018, 491 subjects were screened and 382 were randomised. Both the susceptibility-guided and the empiric regimens were highly successful with per-protocol eradication rates of 97.7% (250/256) vs 97.6% (81/83, P = 1.00) and intent-to-treat eradication rates of 91.6% (262/286) vs 85.4% (82/96, P = 0.12). Overall, susceptibility-guided therapy was not superior to empiric therapy with 0.1% per-protocol (95% CI -3.1% to 3.2%) and 6.2% intent-to-treat (-0.3% to 12.7%) eradication difference. Both approaches had high adherence and low adverse event rates. CONCLUSIONS Both susceptibility-guided and empiric therapies provided excellent eradication rates. Clinically, the choice would hinge on availability of susceptibility testing and/or a locally highly effective empiric therapy.
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21
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Blümel B, Goelz H, Kist M, Glocker EO. Retrospective study on outcome of salvage Helicobacter pylori eradication therapies based on molecular genetic susceptibility testing. Helicobacter 2018; 23:e12494. [PMID: 29873430 DOI: 10.1111/hel.12494] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Antimicrobial susceptibility of Helicobacter (H.) pylori is usually determined by phenotypic methods. When H. pylori cannot be grown owing to contaminations or delay in transport of gastric tissue samples to the microbiological laboratory, molecular genetic testing is a reasonable alternative. The aim of this retrospective study was to assess the outcome of salvage eradication treatments based on molecular genetic susceptibility testing. METHODS Data on 144 H. pylori PCR-positive gastric tissue samples of patients primarily with prior unsuccessful eradication treatments were retrospectively analyzed. Eradication treatments were recommended based on genotypic clarithromycin and/or levofloxacin susceptibility as tested by real-time PCR or reverse hybridization. Treatment success was assessed by attending physicians using urea breath test; stool-antigen ELISA; and microbiology/histopathology. RESULTS Overall success rate of molecular genetic testing-guided salvage treatments was low (68%); none of the regimens chosen was significantly better than another. Multivariable logistic regression analysis did not reveal any factors that may predict treatment failure. CONCLUSIONS Eradication success was poor despite susceptibility testing. Gastroenterologists are advised to prescribe recommended salvage treatments, considering recommended dosages and prolonged treatment duration.
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Affiliation(s)
- Benjamin Blümel
- Faculty of Medicine, Institute of Medical Microbiology and Hygiene, Medical Center-University of Freiburg, Freiburg, Germany
| | - Hanna Goelz
- Faculty of Medicine, Institute of Medical Microbiology and Hygiene, Medical Center-University of Freiburg, Freiburg, Germany
| | - Manfred Kist
- Faculty of Medicine, Institute of Medical Microbiology and Hygiene, Medical Center-University of Freiburg, Freiburg, Germany
| | - Erik-Oliver Glocker
- Faculty of Medicine, Institute of Medical Microbiology and Hygiene, Medical Center-University of Freiburg, Freiburg, Germany.,Brandenburg Medical School, Institute of Laboratory Medicine, Brandenburg Hospital, Brandenburg, Germany
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22
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Branquinho D, Almeida NMPD, Gregório C, Casela A, Donato MM, Tomé L. Twelve-day quintuple regime containing four antibiotics as a rescue therapy for Helicobacter pylori eradication in the central region of Portugal. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 109:430-434. [PMID: 28530108 DOI: 10.17235/reed.2017.4759/2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Helicobacter pylori eradication rates with standard triple therapy in many countries are clinically unacceptable. Fluoroquinolone resistance is increasing and jeopardizing second-line regimens. There is a growing need for an effective strategy in patients who failed previous therapies. METHODS This is a single-center, non-randomized clinical study conducted in the central region of Portugal. Sixty-four patients were included with a positive 13C-urea breath test (UBT) or histology for H. pylori, and at least one failed eradication attempt. The patient cohort included 71.7% of females with a median of age of 52 (range 23-87). They were treated with a twelve-day regimen consisting of a proton-pump inhibitor (PPI) bid, amoxicillin at 1,000 mg 12/12 h and levofloxacin at 500 mg bid during the first seven days, followed by PPI bid, clarithromycin at 500 mg 12/12h and either tinidazole or metronidazole at 500 mg bid/tid for five days. Eradication was assessed by UBT. The local Ethics Committee approved this study. RESULTS Eradication therapy was prescribed due to dyspepsia (66.7%), peptic ulcer (10%) and thrombocytopenia (8.3%). The median number of failed therapies was one (range 1-4). The eradication rate was 64.6% according to an intention-to-treat analysis (95% CI: 53-77%), and 70% by the per-protocol analysis (95% CI: 58-82%). Age, smoking, indication for eradication, previous therapies and the use of a second-generation or full-dose PPI did not affect success rates. CONCLUSIONS Even though treatment with four antibiotics was used, this "reinforced" therapy achieved suboptimal results. This fact highlights the lack of effective H. pylori antimicrobials and suggests that second-line treatment in our region should be prescribed according to susceptibility testing.
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Affiliation(s)
- Diogo Branquinho
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Portugal
| | | | - Carlos Gregório
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra
| | - Adriano Casela
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra
| | | | - Luís Tomé
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra
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The Irish Helicobacter pylori Working Group consensus for the diagnosis and treatment of H. pylori infection in adult patients in Ireland. Eur J Gastroenterol Hepatol 2017; 29:552-559. [PMID: 28350745 DOI: 10.1097/meg.0000000000000822] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Irish eradication rates for Helicobacter pylori are decreasing and there is an increase in the prevalence of antibiotic-resistant bacteria. These trends call into question current management strategies. OBJECTIVE To establish an Irish Helicobacter pylori Working Group (IHPWG) to assess, revise and tailor current available recommendations. METHODS Experts in the areas of gastroenterology and microbiology were invited to join the IHPWG. Questions of relevance to diagnosis, first-line and rescue therapy were developed using the PICO system. A literature search was performed. The 'Grading of Recommendations Assessment, Development and Evaluation' approach was then used to rate the quality of available evidence and grade the resulting recommendations. RESULTS Key resultant IHPWG statements (S), the strength of recommendation and quality of evidence include S8: standard triple therapy for 7 days' duration can no longer be recommended (strong and moderate). S9: 14 days of clarithromycin-based triple therapy with a high-dose proton pump inhibitor (PPI) is recommended as first-line therapy. Bismuth quadruple therapy for 14 days is an alternative if available (strong and moderate). S12: second-line therapy depends on the first-line treatment and should not be the same treatment. The options are (a) 14 days of levofloxacin-based therapy with high-dose PPI, (b) 14 days of clarithromycin-based triple therapy with high-dose PPI or (c) bismuth quadruple therapy for 14 days (strong and moderate). S13: culture and antimicrobial susceptibility testing should be performed following two treatment failures (weak and low/very low). CONCLUSION These recommendations are intended to provide the most relevant current best-practice guidelines for the management of H. pylori infection in adults in Ireland.
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24
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Boltin D, Ben-Zvi H, Perets TT, Gingold-Belfer R, Dickman R, Niv Y. Appropriateness of Repeating Helicobacter pylori Culture and Susceptibility Testing Following Failure of Individualized Antibiotic Therapy. Digestion 2017; 92:66-72. [PMID: 27355208 DOI: 10.1159/000435950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 06/14/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Current guidelines recommend direct Helicobacter pylori culture and antibiotic susceptibility testing following 2 failed eradication attempts. If this process is followed and yet subsequent treatment is unsuccessful, it is unclear whether susceptibility testing should be repeated. This is the first study to examine the appropriateness of repeated H. pylori culture and susceptibility testing following failure of individualized treatment. METHODS Between 2007 and 2014, consecutive patients who underwent at least 2 upper gastrointestinal endoscopies with H. pylori culture and susceptibility testing at our institution following several treatment failures were retrospectively identified. Antibiotic susceptibility was recorded and linked to demographic data. RESULTS A total of 68 cultures from 34 patients were included (12 (35.3%) men, 41.4 ± 16.6 years), and 20 (58.8%) cultures had a different antibiotic susceptibility profile on repeat testing (8 (23.5%) with new susceptibility and 13 (38.2%) with new resistance). Acquired resistance to clarithromycin, levofloxacin and metronidazole was observed in 9 (26.5%), 2 (5.9%) and 10 (29.4%) cultures, respectively. Subjects with resistance to ≤1 antibiotic at baseline were more likely to develop resistance to at least 1 antibiotic on subsequent culture, compared to subjects with resistance to ≥2 antibiotics at baseline (13 (100%) vs. 5 (23.8%), p < 0.01). CONCLUSION Repeating H. pylori culture and susceptibility testing usually yields new antimicrobial susceptibility data. However, the clinical usefulness of this approach remains unclear.
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Affiliation(s)
- Doron Boltin
- Department of Gastroenterology, Rabin Medical Center, Beilinson Campus, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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25
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Bouihat N, Burucoa C, Benkirane A, Seddik H, Sentissi S, Al Bouzidi A, Elouennas M, Benouda A. Helicobacter pylori Primary Antibiotic Resistance in 2015 in Morocco: A Phenotypic and Genotypic Prospective and Multicenter Study. Microb Drug Resist 2016; 23:727-732. [PMID: 27996373 DOI: 10.1089/mdr.2016.0264] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Knowledge of local antibiotic resistance is crucial to adaption of the choice of effective empirical first-line treatment for Helicobacter pylori infection. The aim of this study was to evaluate, for the first time in Morocco, the prevalence of the primary resistance of H. pylori to clarithromycin, metronidazole, amoxicillin, levofloxacin, tetracycline, and rifamycin. We conducted a 1-year prospective study (2015), including 255 Moroccan patients referred for gastro-duodenal endoscopy to two hospitals of Rabat (Morocco) and never previously treated for H. pylori infection. Three gastric biopsies were collected: one for histology, one for culture, and one for molecular detection of H. pylori and the mutations in 23S rRNA genes that confer resistance to clarithromycin. Antimicrobial susceptibility testing was performed on isolated strains by Etest and disk diffusion methods. One hundred seventy-seven patients were infected (69.4%). The prevalence of primary resistances of H. pylori to clarithromycin was 29%, 40% to metronidazole, 0% to amoxicillin, tetracycline, and rifamycin, and 11% to levofloxacin. Only four isolates (2%) were resistant to both clarithromycin and metronidazole. The high level of primary clarithromycin resistance in the H. pylori strains infecting the Moroccan population leads us to recommend the abandonment of the standard clarithromycin-based triple therapy as a first-line treatment in Morocco and to prefer a concomitant quadruple therapy.
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Affiliation(s)
- Najat Bouihat
- 1 Laboratoire de Microbiologie, Université Mohammed V, Hôpital Universitaire Cheick-Zaid , Faculté de Médecine de Rabat, Rabat, Morocco
| | - Christophe Burucoa
- 2 EA 4331 LITEC, Université de Poitiers , CHU de Poitiers, Laboratoire de Bactériologie-Hygiène, Poitiers, France
| | - Ahmed Benkirane
- 3 Departement de Gastroentérologie II, Hôpital Militaire d'Instruction Mohammed V , Rabat, Morocco
| | - Hassan Seddik
- 3 Departement de Gastroentérologie II, Hôpital Militaire d'Instruction Mohammed V , Rabat, Morocco
| | - Sara Sentissi
- 3 Departement de Gastroentérologie II, Hôpital Militaire d'Instruction Mohammed V , Rabat, Morocco
| | - Abderrahmane Al Bouzidi
- 4 Pôle des laboratoires, Hôpital Militaire d'Instruction Mohamed V, équipe de recherche en pathologie tumorale, Faculté de Médecine de Rabat , Rabat, Morocco
| | - Mustapha Elouennas
- 5 Laboratoire de Microbiologie, Hôpital Militaire d'Instruction Mohammed V , Rabat, Morocco
| | - Amina Benouda
- 6 Laboratoire de Microbiologie, Hôpital Universitaire Cheick-Zaid, Université Abulcasis des Sciences de la Santé , Rabat, Morocco
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Lee YC, Chiang TH, Liou JM, Chen HH, Wu MS, Graham DY. Mass Eradication of Helicobacter pylorito Prevent Gastric Cancer: Theoretical and Practical Considerations. Gut Liver 2016; 10:12-26. [PMID: 26696028 PMCID: PMC4694730 DOI: 10.5009/gnl15091] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Although the age-adjusted incidence of gastric cancer is declining, the absolute number of new cases of gastric cancer is increasing due to population growth and aging. An effective strategy is needed to prevent this deadly cancer. Among the available strategies, screen-and-treat for Helicobacter pylori infection appears to be the best approach to decrease cancer risk; however, implementation of this strategy on the population level requires a systematic approach. The program also must be integrated into national healthcare priorities to allow the limited resources to be most effectively allocated. Implementation will require adoption of an appropriate screening strategy, an efficient delivery system with a timely referral for a positive test, and standardized treatment regimens based on clinical efficacy, side effects, simplicity, duration, and cost. Within the population, there are subpopulations that vary in risk such that a "one size fits all" approach is unlikely to be ideal. Sensitivity analyses will be required to identify whether the programs can be utilized by heterogeneous populations and will likely require adjustments to accommodate the needs of subpopulations.
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Affiliation(s)
- Yi-Chia Lee
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Tsung-Hsien Chiang
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jyh-Ming Liou
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Hsiu-Hsi Chen
- Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - David Y Graham
- Department of Medicine, Michael E. DeBakey VA Medical Center, and Baylor College of Medicine, Houston, TX, USA
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27
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Attitudes and practice related to Helicobacter pylori infection among primary care physicians. Eur J Gastroenterol Hepatol 2016; 28:1035-40. [PMID: 27167452 DOI: 10.1097/meg.0000000000000659] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Helicobacter pylori infection is a major public health concern and primary care physicians (PCPs) are at the forefront of H. pylori management. We aimed to assess PCP attitudes related to H. pylori and identify areas where PCP practice deviates from the accepted guidelines. METHODS A 13-item multiple-choice internet-based questionnaire was distributed to PCPs on a national level. Five questions were related to H. pylori detection, two were related to treatment, three were related to gastric cancer, and three were related to screening. The Maastricht IV/Florence Consensus Report was used as the benchmark for correct responses. RESULTS A total of 314 PCP responses were included [140 (52%) men, age 48.2±12.9 years]. Of the total, 292 (93.0%) prescribed clarithromycin-based triple therapy for first-line treatment, 95 (30.3%) prescribed levofloxacin or bismuth-based protocols for second-line treatment, and 137 (43.6%) routinely confirmed eradication. Screening relatives of gastric cancer patients and screening before NSAID treatment was reported by 87 (30.9%) and 39 (14.1%) PCPs, respectively. Of all, 130 (45.0%) believed that the organism is definitely carcinogenic and only 188 (65.0%) agreed that H. pylori eradication reduces the risk of developing gastric cancer. Adherence with guidelines was associated with younger age, central urban clinic location, and a high volume of H. pylori patients. CONCLUSION Overall PCP adherence to H. pylori management guidelines is low. Public health agencies should advance educational initiatives aimed at closing these gaps.
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Puig I, López-Góngora S, Calvet X, Villoria A, Baylina M, Sanchez-Delgado J, Suarez D, García-Hernando V, Gisbert JP. Systematic review: third-line susceptibility-guided treatment for Helicobacter pylori infection. Therap Adv Gastroenterol 2016; 9:437-48. [PMID: 27366212 PMCID: PMC4913327 DOI: 10.1177/1756283x15621229] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Susceptibility-guided therapies (SGTs) have been proposed as preferable to empirical rescue treatments after two treatment failures. The aim of this study was to perform a systematic review and meta-analysis evaluating the effectiveness and efficacy of SGT as third-line therapy. METHODS A systematic search was performed in multiple databases. Studies reporting cure rates of Helicobacter pylori with SGT in third-line therapy were selected. A qualitative analysis describing the current evidence and a pooled mean analysis summarizing the cure rates of SGT in third-line therapy was performed. RESULTS No randomized controlled trials or comparative studies were found. Four observational studies reported cure rates with SGT in third-line treatment, and three studies which mixed patients with second- and third-line treatment also reported cure rates with SGT. The majority of the studies included the patients when culture had been already obtained, and so the effectiveness of SGT and empirical therapy has never been compared. A pooled mean analysis including four observational studies (283 patients) showed intention-to-treat and per-protocol eradication rates with SGT of 72% (95% confidence interval 56-87%; I(2) : 92%) and 80% (95% confidence interval 71-90%; I(2) : 80%), respectively. CONCLUSIONS SGT may be an acceptable option as rescue treatment. However, cure rates are, at best, moderate and this approach has never been compared with a well-devised empirical therapy. The evidence in favor of SGT as rescue therapy is currently insufficient to recommend its use.
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Affiliation(s)
| | | | | | - Albert Villoria
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain,Digestive Diseases Unit, Corporació Sanitaria Universitària Parc Taulí, Sabadell, Spain,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - Mireia Baylina
- Internal Medicine Department, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
| | - Jordi Sanchez-Delgado
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain,Digestive Diseases Unit, Corporació Sanitaria Universitària Parc Taulí, Sabadell, Spain,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - David Suarez
- Unitat d’Epidemiologia i Avaluació, Hospital de Sabadell, Sabadell, Spain
| | | | - Javier P. Gisbert
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain,Servicio de Aparato Digestivo, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
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Cosme A, Lizasoan J, Montes M, Tamayo E, Alonso H, Mendarte U, Martos M, Fernández-Reyes M, Saraqueta C, Bujanda L. Antimicrobial Susceptibility-Guided Therapy Versus Empirical Concomitant Therapy for Eradication of Helicobacter pylori in a Region with High Rate of Clarithromycin Resistance. Helicobacter 2016; 21:29-34. [PMID: 25982426 DOI: 10.1111/hel.12231] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Nonbismuth quadruple (concomitant) regimen is recommended for first-line empirical Helicobacter pylori (HP) eradication treatment when clarithromycin resistance is more than 15-20%. Our objective was to evaluate the efficacy and tolerability of concomitant versus antimicrobial susceptibility-guided treatment in an area with high rates of clarithromycin resistance. METHODS Three hundred consecutive HP-infected patients received antimicrobial susceptibility-guided therapy or empirical concomitant therapy for 10 days. The concomitant regimen was omeprazole (20 mg/12 hour), amoxicillin (1 g/12 hour), clarithromycin (500 mg/12 hour), and metronidazole (500 mg/12 hour) (OACM). Patients diagnosed by culture received one of three combinations of antibiotics based on susceptibility results: omeprazole, amoxicillin, and clarithromycin (OAC); omeprazole, amoxicillin, and levofloxacin (OAL); or omeprazole, amoxicillin, and metronidazole (OAM), at the aforementioned doses (and 500 mg/12 hour in the case of levofloxacin). Eradication was confirmed with a (13)C urea breath test, 6 weeks after treatment. Adverse events and adherence were assessed with questionnaires and reviewing medication sachets. RESULTS The mean age was 50 years, 59% were women, and 14% had peptic ulcers. Concomitant and antimicrobial susceptibility-guided eradication rates were, respectively, 87% and 94% by intention-to-treat (p = .08) and 89% and 95% (p = .08) per protocol per-protocol analysis. Adverse effects were reported in 31% of patients on OACM and 15% of those on susceptibility-guided therapy (p < .05). CONCLUSIONS For HP eradication in a region with high rates of multiple drug resistance, antimicrobial susceptibility-guided therapy is more effective than empirical concomitant therapy.
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Affiliation(s)
- Angel Cosme
- Gastroenterology Department, Donostia Hospital-Biodonostia Health Research Institute, University of Basque Country (UPV/EHU), Centro de Investigación Biomédica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), San Sebastián, Spain
| | - Jacobo Lizasoan
- Gastroenterology Department, Donostia Hospital-Biodonostia Health Research Institute, University of Basque Country (UPV/EHU), Centro de Investigación Biomédica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), San Sebastián, Spain
| | - Milagrosa Montes
- Microbiology Department, Hospital Universitario Donostia - Instituto Biodonostia, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), San Sebastián, Spain
| | - Esther Tamayo
- Microbiology Department, Hospital Universitario Donostia - Instituto Biodonostia, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), San Sebastián, Spain
| | - Horacio Alonso
- Gastroenterology Department, Donostia Hospital-Biodonostia Health Research Institute, University of Basque Country (UPV/EHU), Centro de Investigación Biomédica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), San Sebastián, Spain
| | - Usua Mendarte
- Gastroenterology Department, Donostia Hospital-Biodonostia Health Research Institute, University of Basque Country (UPV/EHU), Centro de Investigación Biomédica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), San Sebastián, Spain
| | - Maider Martos
- Gastroenterology Department, Donostia Hospital-Biodonostia Health Research Institute, University of Basque Country (UPV/EHU), Centro de Investigación Biomédica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), San Sebastián, Spain
| | - María Fernández-Reyes
- Microbiology Department, Hospital Universitario Donostia - Instituto Biodonostia, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), San Sebastián, Spain
| | - Cristina Saraqueta
- Epidemiology Department, Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Donostia Hospital, San Sebastián, Spain
| | - Luis Bujanda
- Gastroenterology Department, Donostia Hospital-Biodonostia Health Research Institute, University of Basque Country (UPV/EHU), Centro de Investigación Biomédica en Red de Enfermedades Hepaticas y Digestivas (CIBERehd), San Sebastián, Spain
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Chen H, Dang Y, Zhou X, Liu B, Liu S, Zhang G. Tailored Therapy Versus Empiric Chosen Treatment for Helicobacter pylori Eradication: A Meta-Analysis. Medicine (Baltimore) 2016; 95:e2750. [PMID: 26886617 PMCID: PMC4998617 DOI: 10.1097/md.0000000000002750] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Although various regimens are empirically accepted for Helicobacter pylori eradication, the efficacy might be declined by multiple individual factors. The necessity of a personalized eradication therapy still remains controversial. The aim of the study was to compare tailored therapy with empiric chosen regimens. Databases of PUBMED, EMBASE, and MEDLINE were searched for eligible studies, published up to October 2015. All relevant controlled clinical trials were included. A random-effect model was applied to compare pooled relative risk (RR) with related 95% confidence intervals (CIs).Thirteen controlled clinical trials integrating 3512 participants were assessed. Overall, the pooled eradication rates of tailored groups were higher than those of empiric ones (intention-to-treat: RR = 1.16, 95% CI 1.10-1.22; preprotocol: RR = 1.14, 95% CI 1.08-1.21). In subgroup analysis, tailored therapy was superior to 7-day standard triple therapy (RR = 1.22, 95% CI 1.16-1.29) and bismuth-quadruple therapy (RR = 1.14, 95% CI 1.07-1.22) on eradication rates; first-line tailored therapy achieved higher eradication rates than first-line empirical regimens (pooled RR = 1.18, 95%CI 1.14-1.22), whereas tailored rescue regimen showed no difference with empirical ones (pooled RR = 1.16, 95% CI 0.96-1.39). Moreover, among different tailored designs, susceptibility-guided tailored therapy obtained higher eradication rates than empiric groups, independent of CYP2C19 genotype detection (with CYP: RR = 1.16, 95% CI 1.09-1.23; without CYP: RR = 1.14, 95% CI 1.01-1.28). Both molecular test-based and culture-based tailored groups were better on eradication rates than empiric groups (molecular: RR = 1.23, 95% CI 1.11-1.35; culture: RR = 1.13, 95% CI 1.06-1.20). Compared with empiric chosen treatments, tailored therapy is a better alternative for H pylori eradication.
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Affiliation(s)
- Han Chen
- From the Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, First Clinical Medical College of Nanjing Medical University, Nanjing, China
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Abstract
Helicobacter pylori is a common worldwide bacterium, possessing adaptability that has created difficulty achieving eradication. While the standard treatment was thought to be triple therapy with a proton pump inhibitor, amoxicillin, and clarithromycin, growing rates of treatment failure and antibiotic resistance have stimulated research into novel regimens. Quadruple therapy with bismuth has been compared for both first- and second-line treatments, but eradication still has not reached expected goals. Innovative regimens including sequential and concomitant therapy, as well as the introduction of new antibiotics into previous treatment schedules, have shown promising improvements in eradication rates. We discuss and compare these unique regimens, reviewing the current literature to deduce those which are most likely to provide the highest success in curing H. pylori infection.
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Affiliation(s)
- Frank J Senatore
- a Department of Internal Medicine , University of Connecticut Health Center , Farmington , CT , USA
| | - Jonathan Wilmot
- b Department of Gastroenterology and Hepatology , University of Connecticut Health Center , Farmington , CT , USA
| | - John W Birk
- b Department of Gastroenterology and Hepatology , University of Connecticut Health Center , Farmington , CT , USA
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Graham DY. Editorial--Avoiding Unethical Helicobacter pylori Clinical Trials: Susceptibility-Based Studies and Probiotics as Adjuvants. Helicobacter 2015; 20:321-5. [PMID: 26123529 PMCID: PMC5098213 DOI: 10.1111/hel.12244] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
As a general rule, any clinical study where the result is already known or when the investigator(s) compares an assigned treatment against another assigned treatment known to be ineffective in the study population (e.g., in a population with known clarithromycin resistance) is unethical. As susceptibility-based therapy will always be superior to empiric therapy in any population with a prevalence of antimicrobial resistance >0%, any trial that randomizes susceptibility-based therapy with empiric therapy would be unethical. The journal Helicobacter welcomes susceptibility or culture-guided studies, studies of new therapies, and studies of adjuvants and probiotics. However, the journal will not accept for review any study we judge to be lacking clinical equipoise or which assign subjects to a treatment known to be ineffective, such as a susceptibility-based clinical trial with an empiric therapy comparator. To assist authors, we provide examples and suggestions regarding trial design for comparative studies, for susceptibility-based studies, and for studies testing adjuvants or probiotics.
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Affiliation(s)
- David Y. Graham
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
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Draeger S, Wüppenhorst N, Kist M, Glocker EO. Outcome of second- and third-line Helicobacter pylori eradication therapies based on antimicrobial susceptibility testing. J Antimicrob Chemother 2015; 70:3141-5. [PMID: 26245638 DOI: 10.1093/jac/dkv223] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 06/26/2015] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES The objective of this study was to assess the outcome of antimicrobial susceptibility-guided therapies in Helicobacter pylori-infected individuals who had undergone unsuccessful prior eradication treatments. METHODS From October 2004 to December 2013, 481 H. pylori-positive patients with prior unsuccessful eradication treatments were administered susceptibility-guided salvage eradication treatments. Six months on, treatment outcome was assessed by urea breath test, stool antigen ELISA, Helicobacter urease test or microbiology and/or histopathology. RESULTS Resistance to metronidazole and clarithromycin was high in patients with prior unsuccessful eradication treatments and was dependent on the number of treatment failures. Susceptibility-guided salvage eradication treatments achieved eradication rates of nearly 70% in these patients. No particular regimen was significantly better than another. CONCLUSIONS Antimicrobial susceptibility testing prevents prescription of inefficient antimicrobials and enables individualized and promising salvage treatments in patients with prior unsuccessful eradication treatments.
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Affiliation(s)
- Sarah Draeger
- National Reference Centre for Helicobacter pylori, Department of Medical Microbiology and Hygiene, Institute of Medical Microbiology and Hygiene, University Medical Centre Freiburg, Hermann-Herder-Straße 11, 79104 Freiburg, Germany
| | - Nicole Wüppenhorst
- National Reference Centre for Helicobacter pylori, Department of Medical Microbiology and Hygiene, Institute of Medical Microbiology and Hygiene, University Medical Centre Freiburg, Hermann-Herder-Straße 11, 79104 Freiburg, Germany
| | - Manfred Kist
- National Reference Centre for Helicobacter pylori, Department of Medical Microbiology and Hygiene, Institute of Medical Microbiology and Hygiene, University Medical Centre Freiburg, Hermann-Herder-Straße 11, 79104 Freiburg, Germany
| | - Erik-Oliver Glocker
- National Reference Centre for Helicobacter pylori, Department of Medical Microbiology and Hygiene, Institute of Medical Microbiology and Hygiene, University Medical Centre Freiburg, Hermann-Herder-Straße 11, 79104 Freiburg, Germany
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Ang TL, Fock KM, Song M, Ang D, Kwek ABE, Ong J, Tan J, Teo EK, Dhamodaran S. Ten-day triple therapy versus sequential therapy versus concomitant therapy as first-line treatment for Helicobacter pylori infection. J Gastroenterol Hepatol 2015; 30:1134-9. [PMID: 25639278 DOI: 10.1111/jgh.12892] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/02/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Clarithromycin-based triple therapy (TT) is the first-line treatment for Helicobacter pylori infection in Singapore. There is awareness that TT may no longer be effective due to increased clarithromycin resistance rates. Sequential therapy (ST) and concomitant therapy (CT) are alternative treatment regimens. This study aimed to compare the efficacy of 10-day TT, ST, and CT as first-line treatment for H. pylori infection. METHODS A randomized study conducted in a teaching hospital. Patients aged 21 years and older with newly diagnosed H. pylori infection were randomized to 10-day TT, ST, or CT. Treatment outcome was assessed by 13-carbon urea breath test at least 4 weeks after therapy. Intention to treat (ITT), modified ITT (MITT), and per protocol (PP) analyses of the eradication rates were performed. RESULTS A total of 462 patients were enrolled (ST: 154; TT 155; CT 153). Patient demographics were similar. Eradication rates for ST versus TT versus CT: ITT analysis: 84.4% versus 83.2% versus 81.7% (P = not significant [NS]); MITT analysis: 90.3% versus 92.1% versus 94.7% (P = NS); PP analysis: 94.1% versus 92.8% versus 95.4% (P = NS). Antibiotic resistance rates for amoxicillin, clarithromycin, and metronidazole were 4.7%, 17.9%, and 48.1%, respectively. Dual clarithromycin and metronidazole resistance occurred in 7.5%. Dual resistance and lack of compliance were predictors of treatment failure. CONCLUSIONS TT, ST, and CT all achieved eradication rates above 80% on ITT and above 90% on MITT and PP analyses. Dual resistance and lack of compliance were predictors of treatment failure (clinicaltrials.gov: NCT02092506).
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Mingjun Song
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Daphne Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Andrew Boon Eu Kwek
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jeannie Ong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Jessica Tan
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Eng Kiong Teo
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Subbiah Dhamodaran
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
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López-Góngora S, Puig I, Calvet X, Villoria A, Baylina M, Muñoz N, Sanchez-Delgado J, Suarez D, García-Hernando V, Gisbert JP. Systematic review and meta-analysis: susceptibility-guided versus empirical antibiotic treatment for Helicobacter pylori infection. J Antimicrob Chemother 2015; 70:2447-55. [PMID: 26078393 DOI: 10.1093/jac/dkv155] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 05/16/2015] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The cure rate of standard triple therapy for Helicobacter pylori infection is unacceptably low. Susceptibility-guided therapies (SGTs) have been proposed as an alternative to standard empirical treatments. The aim of this study was to perform a systematic review and meta-analysis evaluating the efficacy of SGTs. METHODS A systematic search was performed in multiple databases. Randomized controlled trials comparing cure rates of SGTs versus those of empirical therapy were selected and analysed separately for first- and second-line treatments. A meta-analysis was performed using risk ratio (RR) and number needed to treat (NNT) to measure the effect. RESULTS Twelve studies were included in the meta-analysis. In first-line treatment, SGT was more efficacious than empirical 7-10 day triple therapy (RR 1.16, 95% CI 1.10-1.23, I (2) = 33%; NNT = 8). Most studies used a 7-10 day triple therapy and randomized the patients after endoscopy and/or culture, thus precluding the comparison of SGT versus non-invasive testing and empirical treatment in clinical practice. For second-line therapy, only four studies were found. Results were highly heterogeneous and no significant differences were found (RR 1.11, 95% CI 0.82-1.51, I (2) = 87%). CONCLUSIONS Once endoscopy and culture have been performed, SGT is superior to empirical 7 or 10 day triple therapy for first-line treatment. Further studies are needed to evaluate the effectiveness of SGT in clinical practice, especially when compared with currently recommended first-line quadruple therapies.
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Affiliation(s)
- Sheila López-Góngora
- Internal Medicine Department, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
| | - Ignasi Puig
- Digestive Diseases Unit, Althaia Xarxa Assistencial, Universitaria de Manresa, Barcelona, Spain Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain Departament de Medicina, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Xavier Calvet
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain Digestive Diseases Unit, Corporació Sanitaria Universitària Parc Taulí, Sabadell, Spain Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - Albert Villoria
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain Digestive Diseases Unit, Corporació Sanitaria Universitària Parc Taulí, Sabadell, Spain Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - Mireia Baylina
- Internal Medicine Department, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
| | - Neus Muñoz
- Internal Medicine Department, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
| | - Jordi Sanchez-Delgado
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain Digestive Diseases Unit, Corporació Sanitaria Universitària Parc Taulí, Sabadell, Spain Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain
| | - David Suarez
- Unitat d'Epidemiologia i Avaluació, Hospital de Sabadell, Sabadell, Spain
| | - Victor García-Hernando
- Internal Medicine Department, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
| | - Javier P Gisbert
- Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Madrid, Spain Servicio de Aparato Digestivo, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
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Gong YN, Li YM, Yang NM, Li HZ, Guo F, Lin L, Wang QY, Zhang JK, Ji ZZ, Mao JB, Mao JL, Shi ZC, Tang WH, Zhu XJ, Shao W, Zhang XF, Wang XH, Tong YF, Jiang MZ, Chen GL, Wang ZY, Tu HM, Jiang GF, Wu JS, Chen XP, Ding QL, Ouyang H, Jin FZ, Xu YL, Zhang JZ. Centralized isolation of Helicobacter pylori from multiple centers and transport condition influences. World J Gastroenterol 2015; 21:944-952. [PMID: 25624729 PMCID: PMC4299348 DOI: 10.3748/wjg.v21.i3.944] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/11/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy of centralized culture and possible influencing factors.
METHODS: From January 2010 to July 2012, 66452 patients with suspected Helicobacter pylori (H. pylori) infection from 26 hospitals in Zhejiang and Jiangsu Provinces in China underwent gastrointestinal endoscopy. Gastric mucosal biopsies were taken from the antrum for culture. These biopsies were transported under natural environmental temperature to the central laboratory in Hangzhou city and divided into three groups based on their transport time: 5, 24 and 48 h. The culture results were reported after 72 h and the positive culture rates were analyzed by a χ2 test. An additional 5736 biopsies from H. pylori-positive patients (5646 rapid urease test-positive and 90 14C-urease breath test-positive) were also cultured for quality control in the central laboratory setting.
RESULTS: The positive culture rate was 31.66% (21036/66452) for the patient samples and 71.72% (4114/5736) for the H. pylori-positive quality control specimens. In the 5 h transport group, the positive culture rate was 30.99% (3865/12471), and 32.84% (14960/45553) in the 24 h transport group. In contrast, the positive culture rate declined significantly in the 48 h transport group (26.25%; P < 0.001). During transportation, the average natural temperature increased from 4.67 to 29.14 °C, while the positive culture rate declined from 36.67% (1462/3987) to 24.12% (1799/7459). When the temperature exceeded 24 °C, the positive culture rate decreased significantly, especially in the 48 h transport group (23.17%).
CONCLUSION: Transportation of specimens within 24 h and below 24 °C is reasonable and acceptable for centralized culture of multicenter H. pylori samples.
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Park CS, Lee SM, Park CH, Koh HR, Jun CH, Park SY, Lee WS, Joo YE, Kim HS, Choi SK, Rew JS. Pretreatment antimicrobial susceptibility-guided vs. clarithromycin-based triple therapy for Helicobacter pylori eradication in a region with high rates of multiple drug resistance. Am J Gastroenterol 2014; 109:1595-602. [PMID: 25091062 DOI: 10.1038/ajg.2014.222] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 06/22/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Helicobacter pylori eradication rates with clarithromycin-based triple therapy are declining, and an alternative strategy is needed urgently. We sought to compare the efficacy of pretreatment antimicrobial susceptibility-guided vs. clarithromycin-based triple therapy for H. pylori eradication in a region with high rates of multiple drug resistance. METHODS Consecutive H. pylori-infected patients with gastric epithelial neoplasms were randomized to receive antimicrobial susceptibility-guided therapy or clarithromycin-based triple therapy for 7 days. In patients in whom the infection was not eradicated, antibiotics were given according to an initial antimicrobial susceptibility test as a second-line therapy in both groups. Eradication rates, antibiotics resistance rates, and drug compliance owing to adverse effects were compared between the groups. RESULTS In total, 114 patients were enrolled, and 112 completed the protocols. Drug compliance and side effects were similar between the groups. The intention-to-treat eradication rates were 94.7% (95% confidence interval (CI)=88.8-100%, 54/57) in the antimicrobial susceptibility-guided group and 71.9% (95% CI=60.2-83.5%, 41/57) in the clarithromycin-based triple therapy group after the initial treatment (P=0.002), whereas the per-protocol (PP) eradication rates were 96.4% (95% CI=91.5-100%, 54/56) in the antimicrobial susceptibility-guided group and 73.2% (95% CI=61.5-84.8%, 41/56) in the clarithromycin-based triple therapy group (P=0.001). In H. pylori with clarithromycin resistance, the eradication failure rate with first-line treatment was lower in the susceptibility-guided therapy group (0%, 0/12) compared with the clarithromycin-based triple therapy group (80.0%, 95% CI=59.7-100%, 12/15) by PP analysis (P<0.001). CONCLUSIONS Pretreatment antimicrobial susceptibility-guided therapy is more effective than clarithromycin-based triple therapy for H. pylori eradication in a region with high rates of multiple drug resistance.
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Affiliation(s)
- Chung-Su Park
- 1] Department of Internal Medicine, Research Institute of Medical Sciences, Chonnam National University Medical School, Gwangju, Korea [2] The first two authors contributed equally to this work
| | - Su-Mi Lee
- 1] Department of Internal Medicine, Research Institute of Medical Sciences, Chonnam National University Medical School, Gwangju, Korea [2] The first two authors contributed equally to this work
| | - Chang-Hwan Park
- Department of Internal Medicine, Research Institute of Medical Sciences, Chonnam National University Medical School, Gwangju, Korea
| | - Han-Ra Koh
- Department of Internal Medicine, Research Institute of Medical Sciences, Chonnam National University Medical School, Gwangju, Korea
| | - Chung-Hwan Jun
- Department of Internal Medicine, Research Institute of Medical Sciences, Chonnam National University Medical School, Gwangju, Korea
| | - Seon-Young Park
- Department of Internal Medicine, Research Institute of Medical Sciences, Chonnam National University Medical School, Gwangju, Korea
| | - Wan-Sik Lee
- Department of Internal Medicine, Research Institute of Medical Sciences, Chonnam National University Medical School, Gwangju, Korea
| | - Young-Eun Joo
- Department of Internal Medicine, Research Institute of Medical Sciences, Chonnam National University Medical School, Gwangju, Korea
| | - Hyun-Soo Kim
- Department of Internal Medicine, Research Institute of Medical Sciences, Chonnam National University Medical School, Gwangju, Korea
| | - Sung-Kyu Choi
- Department of Internal Medicine, Research Institute of Medical Sciences, Chonnam National University Medical School, Gwangju, Korea
| | - Jong-Sun Rew
- Department of Internal Medicine, Research Institute of Medical Sciences, Chonnam National University Medical School, Gwangju, Korea
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Cammarota G, Ianiro G, Bibbò S, Di Rienzo TA, Masucci L, Sanguinetti M, Gasbarrini A. Culture-guided treatment approach for Helicobacter pylori infection: Review of the literature. World J Gastroenterol 2014; 20:5205-5211. [PMID: 24833850 PMCID: PMC4017035 DOI: 10.3748/wjg.v20.i18.5205] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 12/09/2013] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
The progressive loss of efficacy of standard eradication therapies has made the treatment of Helicobacter pylori (H. pylori) more challenging than ever. Endoscopic-guided antibiotic susceptibility testing had previously been suggested to guide treatment after failure of second-line therapies. However, its role has expanded over the years, in accordance with the current Maastricht Guidelines. Several authors have dealt with this topic, developing both efficacy trials and cost-effectiveness trials against resistant H. pylori infections as well as infections in naïve patients. However, results are not homogeneous enough to provide definite advice, because antibiotic resistance is not the only reason for treatment failure. Moreover, the culture-guided approach is surrounded by many practical issues, such as the availability of both endoscopy units and microbiology laboratories, and the need for a standard of quality that cannot be satisfied everywhere. Finally, pre-treatment susceptibility testing should be part - and not the only weapon - of a targeted, personalized strategy to overcome H. pylori infection.
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Federico A, Gravina AG, Miranda A, Loguercio C, Romano M. Eradication of Helicobacter pylori infection: Which regimen first? World J Gastroenterol 2014; 20:665-672. [PMID: 24574740 PMCID: PMC3921476 DOI: 10.3748/wjg.v20.i3.665] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 11/07/2013] [Accepted: 12/04/2013] [Indexed: 02/06/2023] Open
Abstract
Helicobacter pylori (H. pylori) is a well-known human pathogen that plays an essential role in the pathogenesis of chronic gastritis, peptic ulcer disease, and gastric malignancies. Although H. pylori is susceptible to several antimicrobials, this infection has proven challenging to cure because of the increasing prevalence of bacterial strains that are resistant to the most commonly used antimicrobials, particularly clarithromycin. An effective (i.e., > 90%) first-line therapy is mandatory for avoiding supplementary treatments and testing, and more importantly for preventing the development of secondary resistance. This study reviews the recent literature on first-line therapies for H. pylori. The eradication rates following standard triple therapy (a proton pump inhibitor plus amoxicillin and clarithromycin) for H. pylori infection are declining worldwide. Several first-line strategies have been proposed to increase the eradication rate, including extending the treatment duration to 14 d, the use of a four-drug regimen (bismuth-containing quadruple, sequential, and concomitant treatments), and the use of novel antibiotics, such as fluoroquinolones. However, the efficacy of these regimens is controversial. A first-line eradication regimen should be based on what works best in a defined geographical area and must take into account the prevalence of antimicrobial resistance in that region.
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Tonkic A, Tonkic M, Brnic D, Novak A, Puljiz Z, Simunic M. Time trends of primary antibiotic resistance ofHelicobacter pyloriisolates in Southern Croatia. J Chemother 2013; 24:182-4. [DOI: 10.1179/1973947812y.0000000001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Liang X, Xu X, Zheng Q, Zhang W, Sun Q, Liu W, Xiao S, Lu H. Efficacy of bismuth-containing quadruple therapies for clarithromycin-, metronidazole-, and fluoroquinolone-resistant Helicobacter pylori infections in a prospective study. Clin Gastroenterol Hepatol 2013; 11:802-7.e1. [PMID: 23376004 DOI: 10.1016/j.cgh.2013.01.008] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 01/03/2013] [Accepted: 01/14/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We assessed the efficacy and safety of 4 bismuth-containing quadruple regimens as empiric therapies for Helicobacter pylori infections in patients who did not respond to previous treatment. METHODS We performed a prospective single-center study of 424 patients with H pylori infection that was not eradicated by previous therapies. Patients were assigned randomly to groups given lansoprazole (30 mg twice daily) and bismuth potassium citrate (220 mg twice daily), along with 500 mg tetracycline and 400 mg metronidazole 4 times daily (LBTM), 500 mg tetracycline and 100 mg furazolidone 3 times daily (LBTF), 1000 mg amoxicillin 3 times and 500 mg tetracycline 4 times daily (LBAT), or 1000 mg amoxicillin and 100 mg furazolidone 3 times daily (LBAF). Eradication was assessed by a (13)C-urea breath test. Antimicrobial susceptibility was assessed in 188 patients by the agar dilution method. RESULTS Per-protocol rates of H pylori eradication were greater than 90% for all regimens: 93.1% for LBTM (95% confidence interval [CI], 88.1%-98.0%), 96.1% for LBTF (95% CI, 92.4%-99.8%), 94.6% for LBAT (95% CI, 90.0%-99.2%), and 99.0% for LBAF (95% CI, 97.0%-100%). The intention-to-treat response rates were 87.9% for LBTM (95% CI, 81.7%-94.0%), 91.7% for LBTF (95% CI, 87.1%-96.3%), 83.8% for LBAT (95% CI, 76.8%-90.9%), and 95.2% for LBAF (95% CI, 91.1%-99.3%). Significantly more patients had infections eradicated by furazolidone-containing regimens than nonfurazolidone regimens (P = .01). Side effects occurred in 33.6% of subjects and occurred significantly more frequently in the LBTM group than the other 3 groups (vs LBTF, P = .006; vs LBAT, P = .003; vs LBAF, P = .02). Metronidazole resistance was 96.8%; no isolates were resistant to amoxicillin, tetracycline, or furazolidone. CONCLUSIONS Four bismuth-containing quadruple therapies achieved greater than 90% eradication of H pylori in patients who did not respond to previous treatment, including patients with metronidazole resistance. For patients allergic to penicillin, tetracycline and either metronidazole- or furazolidone-containing regimens are recommended. ClincialTrials.gov number, NCT01668927.
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Affiliation(s)
- Xiao Liang
- GI Division, Shanghai Jiao-Tong University School of Medicine Renji Hospital, Shanghai Institution of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Shanghai, China
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Kim SG, Song HJ, Choi IJ, Cho WY, Lee JH, Keum B, Lee YC, Kim JG, Park SK, Park BJ, Jung HC. Helicobacter pylori eradication on iatrogenic ulcer by endoscopic resection of gastric tumour: a prospective, randomized, placebo-controlled multi-centre trial. Dig Liver Dis 2013; 45:385-9. [PMID: 23333104 DOI: 10.1016/j.dld.2012.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 11/19/2012] [Accepted: 12/03/2012] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The role of Helicobacter pylori (H. pylori) eradication has not been clarified in the healing of iatrogenic ulcer after endoscopic resection of gastric neoplasm. The aim of this study was to evaluate whether H. pylori eradication could facilitate the healing of iatrogenic ulcer after endoscopic resection of gastric neoplasm. METHODS A total of 232 patients with H. pylori-positive early gastric cancer or gastric adenoma underwent endoscopic resection and were randomly allocated to eradication or placebo group in a prospective, double-blinded, and placebo-controlled manner. The primary outcome was measured by healing rate of ulcer, and the secondary outcomes by reduction rate of ulcer size, relief rate from ulcer-related symptoms, and adverse event rates. RESULTS The healing rate of ulcer was 53% in eradication group and 51.6% in placebo group, respectively (p value=0.95). The reduction rate of ulcer size, relief rate from ulcer-related symptoms and adverse event rates were also not different between two groups. In multivariate analysis, initial ulcer size more than 3 cm and histology of cancer were significant factors affecting iatrogenic ulcer healing. CONCLUSIONS H. pylori eradication did not facilitate iatrogenic ulcer healing at early and late phase after endoscopic resection of gastric neoplasm.
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Affiliation(s)
- Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, South Korea
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Cosme A, Montes M, Martos M, Gil I, Mendarte U, Salicio Y, Piñeiro L, Recasens M, Ibarra B, Sarasqueta C, Bujanda L. Usefulness of antimicrobial susceptibility in the eradication of Helicobacter pylori. Clin Microbiol Infect 2013; 19:379-383. [DOI: 10.1111/j.1469-0691.2012.03844.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
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Xiong LJ, Tong Y, Wang Z, Mao M. Detection of clarithromycin-resistant Helicobacter pylori by stool PCR in children: a comprehensive review of literature. Helicobacter 2013; 18:89-101. [PMID: 23067446 DOI: 10.1111/hel.12016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Helicobacter pylori infection is acquired mainly during childhood. To eradicate H. pylori, clarithromycin-based triple therapy has been recommended in children and adults by the latest Maastricht Consensus. However, the prevalence of clarithromycin-resistant H. pylori was higher in children than that in adults. Therefore, rapid, reliable and noninvasive methods for detecting clarithromycin-resistant H. pylori strains should be developed for children. MATERIALS AND METHODS Studies on evaluating stool PCR in detecting clarithromycin-resistant H. pylori and epidemiological surveys of the prevalence of clarithromycin-resistant H. pylori in children were searched in PubMed (from 1966 to December, 2011) for reviewing. RESULTS The average rates of primary clarithromycin-resistant H. pylori ranged from less than 10% to more than 40% in different regions. The rates of secondary resistance to clarithromycin were higher than primary resistance in the same population. In H. pylori isolated from children, the frequent point mutations that are responsible for the clarithromycin resistance included A2143G, A2142G, A2142C and A2144G, and they varied geographically. Comparing with culture-based susceptibility tests, stool PCR performed excellently for their rapidity, independence of bacterial growth, reproducibility and easy standardization. However, stool PCR showed lower sensitivity but perfect specificity in detection of clarithromycin-resistant H. pylori in children. Methodology and mixed infections of resistant H. pylori strains might contribute to the considerable discrepancies of stool PCR results. CONCLUSION Detection of clarithromycin-resistant H. pylori by stool PCR for children are reliable, rapid, noninvasive methods that are worthy of further clinical promotion. However, more evaluations of stool PCR in detection of clarithromycin-resistant H. pylori in children need to be conducted.
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Affiliation(s)
- Li Jing Xiong
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
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Ang TL, Wang L, Ang D, Chiam P, Fock KM, Teo EK. Is there still a role for empiric first-line triple therapy using proton pump inhibitor, amoxicillin and clarithromycin for Helicobacter pylori infection in Singapore? Results of a time trend analysis. J Dig Dis 2013; 14:100-4. [PMID: 23253473 DOI: 10.1111/1751-2980.12024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study was aimed to assess whether the efficacy of one-week triple therapy comprising of proton pump inhibitor, amoxicillin and clarithromycin (PPI/A/C) on Helicobacter pylori (H. pylori) infection in Singapore has decreased over the duration from 2005 to 2010. METHODS The clinical data of H. pylori-positive patients treated with one-week PPI/A/C in 2005 and 2010 were reviewed retrospectively using a registry database. The primary endpoint was the difference in treatment success rate. RESULTS A total of 465 patients (n = 174 in 2005 and n = 291 in 2010) were analyzed. In 2010, compared with 2005, the mean age of patients was younger (47 vs 56 years, P < 0.001) and the proportion of foreigners was higher (19.9% vs 5.7%, P < 0.001). The success rate of H. pylori eradication remained similar over the two time periods (90.2% in 2005 vs 88.7% in 2010, P = 0.597). Multinomial logistic regression revealed that mean age, gender, diagnosis and nationality had no impact on the success of H. pylori eradication. CONCLUSIONS From 2005 to 2010, there was no significant decrease in the efficacy of one-week PPI/A/C for the treatment of H. pylori infection. This treatment regime remained an effective first-line therapy for H. pylori infection in Singapore.
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Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology, Changi General Hospital, Singapore.
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Sereni G, Azzolini F, Camellini L, Formisano D, Decembrino F, Iori V, Tioli C, Cavina M, Di Mario F, Bedogni G, Sassatelli R. Efficacy of a therapeutic strategy for eradication of Helicobacter pylori infection. World J Gastroenterol 2012; 18:4542-8. [PMID: 22969227 PMCID: PMC3435779 DOI: 10.3748/wjg.v18.i33.4542] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 04/16/2012] [Accepted: 05/26/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the efficacy of our therapeutic strategy for Helicobacter pylori (H. pylori) eradication and to identify predictive factors for successful eradication.
METHODS: From April 2006 to June 2010, we retrospectively assessed 2428 consecutive patients (1025 men, 1403 women; mean age 55 years, age range 18-92 years) with gastric histology positive for H. pylori infection referred to our unit for 13-C urea breath test (UBT), after first-line therapy with proton pump inhibitor (PPI) b.i.d. + amoxicillin 1 g b.i.d. + clarithromycin 500 mg b.i.d. for 7 d. Patients who were still positive to UBT were recommended a second-line therapy (PPI b.i.d. + amoxicillin 1 g b.i.d. + tinidazole 500 mg b.i.d. for 14 d). Third choice treatment was empirical with PPI b.i.d. + amoxicillin 1 g b.i.d. + levofloxacin 250 mg b.i.d. for 14 d.
RESULTS: Out of 614 patients, still H. pylori-positive after first-line therapy, only 326 and 19 patients respectively rechecked their H. pylori status by UBT after the suggested second and third-line regimens. “Per protocol” eradication rates for first, second and third-line therapy were 74.7% (95% CI: 72.7%-76.4%), 85.3% (95% CI: 81.1%-89.1%) and 89.5% (95% CI: 74.9%-103%) respectively. The overall percentage of patients with H. pylori eradicated after two treatments was 97.8% (95% CI: 97.1%-98.4%), vs 99.9% (95% CI: 99.8%-100%) after three treatments. The study found that eradication therapy was most effective in patients with ulcer disease (P < 0.05, P = 0.028), especially in those with duodenal ulcer. Smoking habits did not significantly affect the eradication rate.
CONCLUSION: First-line therapy with amoxicillin and clarithromycin produces an H. pylori eradication rate comparable or superior to other studies and second-line treatment can still be triple therapy with amoxicillin and tinidazole.
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Sung H, Chung HJ, Kim MN, Lee GH. [Clinical Usefulness of Antimicrobial Susceptibility Test for Helicobacter pylori.]. Korean J Lab Med 2012; 26:179-84. [PMID: 18156722 DOI: 10.3343/kjlm.2006.26.3.179] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Antimicrobial resistance of Helicobacter pylori is considered as the main cause of failure of eradication therapy. Because resistance to metronidazole has been reported in 25.8% to 66.2% of H. pylori, a combination of proton pump inhibitors (PPI), amoxicillin, and clarithromycin is currently recommended as a primary therapy. We investigated the prevalence of antimicrobial resistance to the primary drugs and the impact of antimicrobial resistance on eradication rates. METHODS Between May and August 2005, H. pylori isolates from 93 patients were tested for antimicrobial susceptibility at Asan Medical Center. Susceptibility tests of clarithromycin and amoxicillin were performed by the disk diffusion method and those of metronidazole and tetracycline by Etest (AB Biodisk, Solna, Sweden). The medical records of the patients were reviewed to collect the data such as demographic findings, previous and current eradication therapies, and bacteriological outcome. The appropriate therapy was defined as three-drug-combination including susceptible drugs only, or four-drug-combination including metronidazole in the case of metronidazole-resistance. RESULTS Resistance rates to clarithromycin and metronidazole were 17.2% and 33.3%, respectively, but there was no resistance to tetracycline and amoxicillin. The eradication was successful in 32 of the 36 patients (88.9%) who received the appropriate therapy, but none of 4 patients who received an inappropriate therapy (P<0.01). CONCLUSIONS Resistance to clarithromycin seemed to increase and contribute to the failure of eradication therapy. For the appropriate therapy of H. pylori infection, the susceptibility results should be reported before initiation of the eradication therapy.
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Affiliation(s)
- Heungsup Sung
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea.
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Federico A, Nardone G, Gravina AG, Iovene MR, Miranda A, Compare D, Pilloni PA, Rocco A, Ricciardiello L, Marmo R, Loguercio C, Romano M. Efficacy of 5-day levofloxacin-containing concomitant therapy in eradication of Helicobacter pylori infection. Gastroenterology 2012; 143:55-61.e1; quize e13-4. [PMID: 22484118 DOI: 10.1053/j.gastro.2012.03.043] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 03/23/2012] [Accepted: 03/26/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND & AIMS Helicobacter pylori have become resistant to antimicrobial agents, reducing eradication rates. A 10-day sequential regimen that contains levofloxacin was efficient, safe, and cost saving in eradicating H pylori infection in an area with high prevalence of clarithromycin resistance. We performed a noninferiority randomized trial to determine whether a 5-day levofloxacin-containing quadruple concomitant regimen was as safe and effective as the 10-day sequential regimen in eradicating H pylori in previously untreated patients. METHODS We randomly assigned patients with H pylori infection to groups that were given 5 days of concomitant therapy (esomeprazole 40 mg twice daily, amoxicillin 1 g twice daily, levofloxacin 500 mg twice daily, and tinidazole 500 mg twice daily; n = 90) or 10 days of sequential therapy (esomeprazole 40 mg twice daily, amoxicillin 1g twice daily for 5 days followed by esomeprazole 40 mg twice daily, levofloxacin 500 mg twice daily, and tinidazole 500 mg twice daily for 5 more days; n = 90). Antimicrobial resistance was assessed by the E-test. Efficacy, adverse events, and costs were determined. RESULTS Intention-to-treat analysis showed similar eradication rates for concomitant (92.2%; 95% confidence interval [CI], 84.0%-95.8%) and sequential therapies (93.3%; 95% CI, 86.9%-97.3%). Per-protocol eradication results were 96.5% (95% CI, 91%-99%) for concomitant therapy and 95.5% for sequential therapy (95% CI, 89.6%-98.5%). The differences between sequential and concomitant treatments were 1.1% in the intention-to-treat study (95% CI; -7.6% to 9.8%) and -1.0% in the per-protocol analysis (95% CI; -8.0% to 5.9%). The prevalence of antimicrobial resistance and incidence of adverse events were comparable between groups. Concomitant therapy cost $9 less than sequential therapy. CONCLUSIONS Five days of levofloxacin-containing quadruple concomitant therapy is as effective and safe, and less expensive, in eradicating H pylori infection than 10 days of levofloxacin-containing sequential therapy.
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Affiliation(s)
- Alessandro Federico
- Dipartimento Medico Chirurgico di Internistica Clinica e Sperimentale ed UOC di Gastroenterologia e, Napoli, Italy
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Helicobacter pylori eradication rates in children upon susceptibility testing based on noninvasive stool polymerase chain reaction versus gastric tissue culture. J Pediatr Gastroenterol Nutr 2011; 53:65-70. [PMID: 21694538 DOI: 10.1097/mpg.0b013e318210586d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES In children with clarithromycin-resistant Helicobacter pylori, clarithromycin-containing therapies often fail. The present study aimed to assess the outcome of tailored therapy upon noninvasive versus invasive H pylori susceptibility testing. PATIENTS AND METHODS A retrospective cohort study was conducted in a pediatric outpatient clinic located in a region where H pylori clarithromycin resistance is highly prevalent. Between June 2007 and September 2009, 96 infected children (mean age 10.8 years), naïve to H pylori eradication treatment, were prescribed triple eradication therapies. These therapies were individually tailored upon susceptibility testing performed either noninvasively using stool polymerase chain reaction (stool PCR group) or invasively using endoscopy, biopsy, and culturing of gastric biopsies (gastric biopsy group). Eradication was defined by negative results upon noninvasive testing including stool PCR at least 5 weeks after the end of treatment. RESULTS H pylori was eradicated in 43 of 55 stool PCR group versus 30 of 41 gastric biopsy group children (78.2% vs 73.2%, P = 0.63). Of those H pylori strains with pretherapeutic clarithromycin susceptibility, 78.8% were eradicated in the stool PCR group and 69.2% in the gastric biopsy group (P = 0.41) following clarithromycin-containing therapy; clarithromycin resistance was acquired by 4.1% of strains in the former group versus 12% in the latter (P = 0.33). CONCLUSIONS Stool PCR is as effective as the invasive approach of H pylori susceptibility testing for targeting resistance-guided eradication treatments in children. Furthermore, stool PCR is a useful tool for tracking the emergence of clarithromycin resistance following eradication treatment.
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Raymond J, Lamarque D, Kalach N, Chaussade S, Burucoa C. High level of antimicrobial resistance in French Helicobacter pylori isolates. Helicobacter 2010; 15:21-7. [PMID: 20302586 DOI: 10.1111/j.1523-5378.2009.00737.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Helicobacter pylori is a human pathogen responsible for serious diseases including peptic ulcer disease and gastric cancer. The recommended triple therapy included clarithromycin but increasing resistance has undermined its effectiveness. It is therefore important to be aware of the local prevalence of antimicrobial resistance to adjust treatment strategy. MATERIALS AND METHODS Overall, 530 biopsies were collected between 2004 and 2007. The antimicrobial susceptibility of H. pylori was determined by E-test and molecular methods. RESULTS Among these, 138/530 (26%) strains were resistant to clarithromycin, 324/530 (61%) to metronidazole and 70/530 (13.2%) to ciprofloxacin. Whereas no resistance against amoxicillin and tetracycline was observed, only one strain was resistant to rifampicin. Compared to the patients never treated for H. pylori infection, the prevalence of resistance was significantly higher in patients previously treated (19.1% vs 68% for clarithromycin; 13.2% vs 53.3% for both clarithromycin and metronidazole). The trend analysis revealed an increase of primary resistance to ciprofloxacin between 2004 and 2005 (7.3%) vs 2006-2007 (14.1%) (p = .04) and the secondary resistance reached 22.7% in 2007. Interestingly, 27 biopsies (19.6%) contained a double population of clarithromycin-susceptible and -resistant strains. CONCLUSIONS The reported high prevalence of clarithromycin and multiple resistances of H. pylori suggest that the empiric therapy with clarithromycin should be abandoned as no longer pretreatment susceptibility testing has assessed the susceptibility of the strain. As culture and antibiogram are not routinely performable in most clinical laboratories, the use of molecular test should be developed to allow a wide availability of pretreatment susceptibility testing.
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Affiliation(s)
- Josette Raymond
- Université Paris Descartes, Faculté de Médecine, Hôpital Cochin-Saint Vincent de Paul, Service de Bactériologie, Paris, France.
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