Clostridium difficile colitis associated with a 'triple' regimen, containing clarithromycin and metronidazole, to eradicate Helicobacter pylori

Treating Helicobacter pylori and Recurrent Clostridioides difficile Coinfection: A Delicate Balance in Management and a Need for Guidelines

Treating Helicobacter pylori and Clostridioides difficile coinfection presents a challenging clinical dilemma. Treating H. pylori may increase the risk of C. difficile, and antibiotics generally have been shown to increase the risk of C. difficile infection/recurrence. While it may be reasonable to delay H. pylori treatment, this is especially challenging when there is an acute indication to treat H. pylori such as peptic ulceration or bleeding. There are no guidelines on the management of H. pylori and C. difficile coinfection. We report a patient who had H. pylori and recurrent C. difficile coinfection and suggest a management algorithm based on literature review and our institutional experience. Our patient received quadruple therapy for H. pylori along with vancomycin prophylaxis, taper, and a dose of bezlotoxumab and experienced good outcomes with resolution of his gastrointestinal bleeding and diarrhea.

Proton pump inhibitors may enhance the risk of digestive diseases by regulating intestinal microbiota

Proton pump inhibitors (PPIs) are the most used acid-inhibitory drugs, with a wide range of applications in the treatment of various digestive diseases. However, recently, there has been a growing number of digestive complications linked to PPIs, and several studies have indicated that the intestinal flora play an important role in these complications. Therefore, developing a greater understanding of the role of the gut microbiota in PPI-related digestive diseases is essential. Here, we summarize the current research on the correlation between PPI-related digestive disorders and intestinal flora and establish the altered strains and possible pathogenic mechanisms of the different diseases. We aimed to provide a theoretical basis and reference for the future treatment and prevention of PPI-related digestive complications based on the regulation of the intestinal microbiota.

Helicobacter pylori Eradication Therapy-associated Diarrhea

Eradication of Helicobacter pylori has contributed to the treatment of peptic ulcers and mucosa-associated lymphoid tissue lymphoma. Moreover, it has possibly decreased the prevalence of gastric cancer. However, eradication therapy is associated with various adverse effects, of which diarrhea is the most common. The incidence of diarrhea after eradication treatment varies from 8% to 48%. In particular, the incidence is higher in patients who receive first-line standard triple therapy compared with those who receive second-line therapy. Both antibiotics and proton pump inhibitors, components of eradication therapy, have short-term and long-term impacts on gut microbiota. The alterations of gut microbiota may not recover until 1 year after eradication therapy. Most cases of diarrhea that occur after eradication therapy are antibiotic-associated diarrhea caused by the destruction of the normal gut microbiota. In some cases, Clostridioides difficile-associated diarrhea occurs after eradication therapy. If bloody diarrhea occurs after eradication therapy and the Clostridioides difficile toxin is not detected, antibiotic-associated hemorrhagic colitis associated with Klebsiella oxytoca infection should be suspected. It is crucial to explain the possibility of diarrhea before initiating eradication therapy to increase compliance. Furthermore, probiotics may be administered to reduce diarrhea. If severe diarrhea or symptoms other than the usual antibiotic-associated diarrhea occur during or after eradication therapy, antibiotics should be discontinued. In addition, appropriate tests to determine the cause of diarrhea should be performed. This review summarizes the alteration of the gut microbiota, the causes of diarrhea after Helicobacter pylori eradication therapy, and its management.

Treatment of Helicobacter pylori Is Not Associated With Future Clostridium difficile Infection

INTRODUCTION

Helicobacter pylori (HP) infection is associated with many gastrointestinal disorders, including gastric cancer, and consensus guidelines recommend eradication after detection. There is a theoretical, yet uninvestigated, concern that HP treatment could increase the risk of Clostridium difficile infection (CDI). Using the data from a large cohort of patients with HP, we investigated whether HP eradication is associated with CDI.

METHODS

A retrospective cohort study within the Veterans Health Administration on 38,535 patients (median age 61.8 years; 91.8% men) with detected HP between January 1, 1994, and December 31, 2018 was conducted. Primary outcome was a positive laboratory test for CDI within 3 months of HP detection. Multivariable logistic regression evaluated the following: patient demographics, previous CDI, recent hospitalization, and whether the patient received HP eradication therapy (by antibiotic and regimen, and including proton pump therapy). Secondary analysis of those treated evaluated whether eradication of HP was associated with CDI.

RESULTS

Among 38,535 patients, 28,818 (74.8%) were treated for HP and 284 (0.74%) developed CDI. In multivariable analysis, prominent factors included hospital discharge within 12 weeks (odds ratio [OR] 2.15; 95% confidence interval [CI]: 1.22-3.77) and 4 weeks (OR 3.46; 95% CI: 2.18-5.48), P < 0.001, and previous CDI (OR 12.5; 95% CI: 9.21-17.0, P < 0.001). Treatment of HP was not associated with future CDI. In secondary analysis of those treated, confirmation of eradication was not associated with future CDI (OR 1.49; 95% CI: 0.67-3.29).

DISCUSSION

In a large study of US patients with HP, we demonstrate that neither treatment nor eradication of HP is associated with CDI. Previous C. difficile infection and recent hospital discharge, established risk factors for CDI, are strongly associated. These findings suggest that treatment should be continued to be prescribed when HP is detected (http://links.lww.com/AJG/B507).

Clostridium difficile Infection: An Epidemiology Update

Clostridium (reclassified as " Clostridioides ") difficile infection (CDI) is a healthcare-associated infection and significant source of potentially preventable morbidity, recurrence, and death, particularly among hospitalized older adults. Additional risk factors include antibiotic use and severe underlying illness. The increasing prevalence of community-associated CDI is gaining recognition as a novel source of morbidity in previously healthy patients. Even after recovery from initial infection, patients remain at risk for recurrence or reinfection with a new strain. Some pharmaco-epidemiologic studies have suggested an increased risk associated with proton pump inhibitors and protective effect from statins, but these findings have not been uniformly reproduced in all studies. Certain ribotypes of C. difficile , including the BI/NAP1/027, 106, and 018, are associated with increased antibiotic resistance and potential for higher morbidity and mortality. CDI remains a high-morbidity healthcare-associated infection, and better understanding of ribotypes and medication risk factors could help to target treatment, particularly for patients with high recurrence risk.

Doxycycline and Tigecycline: Two Friendly Drugs with a Low Association with Clostridium Difficile Infection

Clostridium difficile infection (CDI) is known to be associated with prior exposure to many classes of antibiotics. Standard therapy for CDI (i.e., metronidazole and vancomycin) is associated with high recurrence rates. Although tetracycline derivatives such as tetracycline, doxycycline or tigecycline are not the standard therapeutic choices for CDI, they may serve as an alternative or a component of combination therapy. Previous tetracycline or doxycycline usage had been shown to have less association with CDI development. Tigecycline, a broad-spectrum glycylcycline with potency against many gram-positive or gram-negative pathogens, had been successfully used to treat severe or refractory CDI. The in vitro susceptibility of C. difficile clinical isolates to tigecycline in many studies showed low minimal inhibitory concentrations. Tigecycline can suppress in vitro toxin production in both historical and hypervirulent C. difficile strains and reduce spore production in a dose-dependent manner. Tetracycline compounds such as doxycycline, minocycline, and tigecycline possess anti-inflammatory properties that are independent of their antibiotic activity and may contribute to their therapeutic effect for CDI. Although clinical data are limited, doxycycline is less likely to induce CDI, and tigecycline can be considered one of the therapeutic choices for severe or refractory CDI.

Pseudomembranous colitis associated with a triple therapy for Helicobacter pylori eradication

Helicobacter pylori (H. pylori) is one of the most common chronic bacterial infections in humans, affecting half of world’s population. Therapy for H. pylori infection has proven to be both effective and safe. The one-week triple therapy including proton pump inhibitor, clarithromycin, and amoxicillin or metronidazole is still recommended as a first-line treatment to eradicate H. pylori infection in countries with low clarithromycin resistance. Generally, this therapy is well-tolerated, with only a few and usually minor side effects. However, rare but severe adverse effects such as pseudomembranous colitis have been reported, Clostridium difficile (C. difficile) infection being the main causative factor in all cases. We report the cases of two women who developed pseudomembranous colitis after a 1-wk triple therapy consisting of pantoprazole 20 mg bid, clarithromycin 500 mg bid, and amoxicillin 1 g bid to eradicate H. pylori infection. A limited colonoscopy showed typical appearance of pseudomembranous colitis, and the stool test for C. difficile toxins was positive. Rapid resolution of symptoms and negative C. difficile toxins were obtained in both patients with oral vancomycin. No relapse occurred during a four and eleven-month, respectively, follow up. These cases suggest that physicians should have a high index of suspicion for pseudomembranous colitis when evaluate patients with diarrhea following H. pylori eradication therapy.

Do we eradicate Helicobacter pylori in hospitalized patients with peptic ulcer disease?

BACKGROUND

Helicobacter pylori infection is the most common chronic infection in humans. It is a major contributor to the cause of duodenal and gastric ulcers worldwide. Its eradication has been shown to reduce rates of H pylori-related ulcers as well as other complications such as gastric cancer.

OBJECTIVE

To determine the rate of appropriate treatment in patients following a diagnosis of H pylori infection on biopsy during esophagoduodenoscopy for upper gastrointestinal bleeding over a four-year period at a tertiary centre in Vancouver, British Columbia. Also evaluated was the rate of eradication confirmation using the urea breath test.

METHODS

A retrospective review of 1501 inpatients who underwent esophagoduodenoscopy for upper gastrointestinal bleeding (January 2006 to December 2010) was undertaken. Patients who were biopsy stain positive for H pylori were selected for drug review either via a provincial database (PharmaNet) or via records from patients' family practitioners. Data were also obtained via two provincial laboratories that perform the urea breath test to determine the rates of confirmation of eradication.

RESULTS

Ninety-eight patients had biopsy-proven H pylori. The mean (± SD) age was 56.13±17.9 years and 65 were male. Data were not available for 22 patients; the treatment rate was 52.6% (40 of 76). Of those treated, 12 patients underwent a post-treatment urea breath test for eradication confirmation.

CONCLUSION

There was substantial discrepancy between the number of diagnosed H pylori infections and the rate of treatment as well as confirmation of eradication. Numerous approaches could be taken to improve treatment and eradication confirmation.

[Probiotics in gastroenterology -- from a different angle]

After a short overview of the history of probiotics, the author presents the development of human intestinal microflora based on the newest genetic data and the microbiological features of main probiotics. The indications of probiotic administration have been defined and extended in recent years. The author reviews significant results of probiotic treatment in some gastrointestinal diseases based on meta-analytical data. Probiotics are useful in preventing and treating diarrhoea caused by antibiotics and Clostridium difficile caused diarrhoea. In the treatment of Helicobacter pylori infection, preparations containing certain Lactobacillus,Bifidobacterium strains or Saccaromyces boulardii could enhance by 5-10% the rate of successful eradication and reduce the incidence and severity of the side effects. Some symptoms of irritable bowel syndrome and thus the quality of life can be improved by probiotics. Their beneficial effect in ulcerative colitis was proven, while in Crohn's disease has not yet been defined. The use of probiotics is not included in guidelines, with the exception of the Maastricht IV/Florence consensus. For each disease it is advisable to use probiotics containing strains only with proven beneficial effect. The efficiency of preparations containing mixed strains has not yet been properly investigated. The author reviews the rare but potentially serious side effects of probiotics. In Hungary, there are many probiotic preparations available which can be purchased in pharmacies without prescription: their use is more empirical than evidence-based. The European Food Safety Authority has recently rejected claims for probiotics to be classed as medicines given the lack of convincing evidence on the effects of probiotics on human health and well-being. Clearly, further research is needed to collect evidence which could be incorporated into the international guidelines.

Adjuvant probiotics improve the eradication effect of triple therapy for Helicobacter pylori infection

AIM: To investigate whether the addition of probiotics can improve the eradication effect of triple therapy for Helicobacter pylori (H. pylori) infection.

METHODS: This open randomized trial recruited 234 H. pylori positive gastritis patients from seven local centers. The patients were randomized to one-week standard triple therapy (omeprazole 20 mg bid, clarithromycin 500 mg bid, and amoxicillin 1000 mg bid; OCA group, n = 79); two weeks of pre-treatment with probiotics, containing 3 × 10⁷Lactobacillus acidophilus per day, prior to one week of triple therapy (POCA group, n = 78); or one week of triple therapy followed by two weeks of the same probiotics (OCAP group, n = 77). Successful eradication was defined as a negative C13 or C14 urease breath test four weeks after triple therapy. Patients were asked to report associated symptoms at baseline and during follow-up, and side effects related to therapy were recorded. Data were analyzed by both intention-to-treat (ITT) and per-protocol (PP) methods.

RESULTS: PP analysis involved 228 patients, 78 in the OCA, 76 in the POCA and 74 in the OCAP group. Successful eradication was observed in 171 patients; by PP analysis, the eradication rates were significantly higher (P = 0.007 each) in the POCA (62/76; 81.6%, 95% CI 72.8%-90.4%) and OCAP (61/74; 82.4%, 95% CI 73.6%-91.2%) groups than in the OCA group (48/78; 61.5%, 95% CI 50.6%-72.4%). ITT analysis also showed that eradication rates were significantly higher in the POCA (62/78; 79.5%, 95% CI 70.4%-88.6%) and OCAP (61/77; 79.2%, 95% CI 70%-88.4%) groups than in the OCA group (48/79; 60.8%, 95% CI 49.9%-71.7%), (P = 0.014 and P = 0.015). The symptom relieving rates in the POCA, OCAP and OCA groups were 85.5%, 89.2% and 87.2%, respectively. Only one of the 228 patients experienced an adverse reaction.

CONCLUSION: Administration of probiotics before or after standard triple therapy may improve H. pylori eradication rates.

Effect and Mechanism of Lactobacillus on treating Mongolian Gerbil with Helicobacter pylori infectious gastritis

AIM: To evaluate the therapeutic efficacy of Bacillus acidi lactici for H pylori-related gastritis in clean grade Mongolian Gerbil model, and to explore its therapeutic mechanism.

METHODS: A total of 32 Mongolian Gerbil rats were infected with H pylori to establish the gastritis model, and then were randomly divided into 4 groups. Eight normal rats were taken as normal control group. The first group was treated with available trigeminy therapy, the second group Bacillus acidi lactici strains, the third group Bacillus acidi lactici plus PPI, and the fourth group sodium chloride solution for 10 d. Four weeks after the last treatment, the mice were all sacrificed. The infection of H pylori in gastric mucosa of the mice was detected using rapid urease test, Giemsa staining and culture. The histopathological changes in the gastric mucosa of mice were estimated using hematoxylin-eosin staining. Then protein expression of COX-2, IL-6 and TNF-α in gastric mucosa were examined using immunocytochemical staining assay.

RESULTS: Mongolian Gerbil model with H pylori infectious gastritis was successfully established. There was no significant difference in eradication of H pylori among the first, the second group and the third group. However, eradication rate in either of the first three groups was significantly lower than the fourth group (87.5%, 75%, 75% vs 100%, all P < 0.05). The chronic inflammatory response of the fourth group was more serious than the first, second and third group, especially in body of stomach (4.2 ± 1.06 vs 1.8 ± 0.54, 2.0 ± 0.48, 1.9 ± 0.50, all P < 0.05), sinus ventriculi (4.6 ± 0.74 vs 1.5 ± 0.27, 1.4 ± 0.33, 1.7 ± 0.46, all P < 0.05) and duodenum (4.1 ± 0.83 vs 1.4 ± 0.41, 1.7 ± 0.29, 1.6 ± 0.52, all P < 0.05). There was no significant difference between the first, second and third group in the chronic inflammatory response. At protein level, there was no IL-6 expression in the normal group, expressions of COX-2, IL-6, TNF-α in the first, the second and the third group were significantly decreased compared with the fourth group (COX-2: 3.57 ± 0.32, 3.89 ± 0.51, 2.95 ± 0.76 vs 6.79 ± 1.68, all P < 0.05; IL-6: 2.42 ± 0.60, 2.28 ± 0.71, 1.93 ± 0.52 vs 5.61 ± 0.28, all P < 0.05; TNF-α: 3.30 ± 0.52, 3.65 ± 0.35, 2.84 ± 0.20 vs 6.76 ± 1.63, all P < 0.05), but were significantly increased compared with the control group.

CONCLUSION: The therapy of Bacillus acidi lactici for H pylori-related gastritis was effective, equal to the available trigeminy therapy. Bacillus acidi lactici therapy for Helicobacter pylori-related gastritis decreases the expression of COX-2, IL-6 and TNF-α in gastric mucosa.

Progress of research into the pathogenic mechanism of Helicobacter pylori and the preventive role of probiotics in H. pylori infection

Helicobacter pylori, a highly prevalent pathogen, is a major cause of chronic gastritis and peptic ulcer and a risk factor for gastric malignancies or gastric mucosa-associated lymphoid tissue (MALT) lymphoma. Antibiotic-based H. pylori eradication is currently regarded as the gold standard. However, it is expensive and causes side effects, and the rapid development of antibiotic-resistant strains may soon prevent their large-scale use. Recently, many new therapeutic strategies are being studied to improve the H. pylori eradication rate. The use of probiotics in the field of H. pylori infection has been proposed for improving eradication, tolerability and compliance with multiple antibiotic regimens. In addition, probiotics have a possible role in the stabilization of the gastric barrier function and reducing mucosal inflammation. In this article, we review the development of research on the molecular mechanism of H. pylori infection and the mechanisms of action and clinical significance of probiotics.

Proton pump inhibitor therapy is a risk factor for Clostridium difficile-associated diarrhoea

BACKGROUND

Inhibition of gastric acid removes a defence against ingested bacteria and spores, increasing the risk of some forms of gastroenteritis. Previous studies investigating a possible link between acid suppression therapy and Clostridium difficile-associated diarrhoea have reported conflicting results.

AIM

To investigate whether acid suppression therapy is associated with an increased risk of C. difficile-associated diarrhoea. Prospective case-control study of 155 consecutive in-patients with C. difficile-associated diarrhoea.

RESULTS

Antibiotics had been received by 143 (92%) of the C. difficile-associated diarrhoea group and 76 (50%) of the controls during the preceding 3 months. Among those receiving antibiotics, 59 (41%) of the C. difficile-associated diarrhoea group had also received acid suppression, compared with 21 (28%) of controls (OR 1.84, CI 1.01, 3.36, chi(2) = 4.0, P = 0.046). Among the entire C. difficile-associated diarrhoea group 64 (41%) had received acid suppression compared with 40 (26%) of controls (OR 1.99, CI 1.19, 3.31, chi(2) = 7.9, P = 0.005). Logistic regression analyses found that C. difficile-associated diarrhoea was independently associated with: antibiotic use (OR 13.1, 95% CI: 6.6, 26.1); acid suppression therapy (OR 1.90, 95% CI: 1.10, 3.29); and female sex (OR 1.79, 95% CI: 1.06, 3.04).

CONCLUSIONS

The risk of C. difficile-associated diarrhoea in hospitalized patients receiving antibiotics may be compounded by exposure to proton pump inhibitor therapy.

Risk of Clostridium difficile diarrhea among hospital inpatients prescribed proton pump inhibitors: cohort and case-control studies

BACKGROUND

Antibiotic disruption of the normal intestinal flora is a well-known risk factor for Clostridium difficile-associated diarrhea. Reduced gastric acidity has been suggested as a risk factor, and we hypothesized that proton pump inhibitors, because of their potency, may be an independent risk factor for this problem.

METHODS

For the cohort study we identified from a pharmacy database 1187 inpatients at a Montreal teaching hospital who received antibiotics over a 9-month period beginning in August 2002. We compared patients in this group who had also received a proton pump inhibitor or an H(2) blocker with patients who had not received acid suppressive therapy. Hospital laboratory reports of positive assay results for C. difficile toxin were used to ascertain cases in the cohort. To assess the possibility that proton pump inhibitors were prescribed to patients who were sicker and had other risk factors for C. difficile infection, we did a case-control study at a second Montreal teaching hospital. Cases were defined as patients who were positive for C. difficile toxin and who had a history of diarrhea (n = 94). Control subjects were selected from among patients who had received an antibiotic and were matched to cases by ward, age within 5 years and class of antibiotics (n = 94).

RESULTS

In the cohort study, C. difficile diarrhea developed in 81 (6.8%) of the 1187 patients who received antibiotics while in hospital. In a multivariate analysis, C. difficile diarrhea was significantly associated with use of proton pump inhibitors (adjusted odds ratio [OR] 2.1, 95% confidence interval [CI] 1.2- 3.5), receipt of 3 or more antibiotics (OR 2.1, 95% CI 1.3- 3.4) and admission to a medical ward (OR 4.1, 95% CI 2.3- 7.3). In the case-control study C. difficile diarrhea was associated with female sex (adjusted OR 2.1, 95% CI 1.1-4.0), prior renal failure (adjusted OR 4.3, 95% CI 1.5-11.9), hospital admission in the 3 months before the index admission (adjusted OR 2.6, 95% CI 1.4-5.2) and use of proton pump inhibitors (adjusted OR 2.7, 95% CI 1.4-5.2).

INTERPRETATION

Patients in hospital who received proton pump inhibitors were at increased risk of C. difficile diarrhea.

Coinfection with Giardia lamblia and Clostridium difficile after Use of Ranitidine

A 49-year-old man presented with a 3-week history of vomiting and diarrhea. He reported foamy stools but no blood or melena and had crampy epigastric pain. He denied usage of antibiotics. He had been taking ranitidine for intermittent epigastric pain for the last few months and noted an 11-pound weight loss during the 3 weeks before admission. Stool was positive for Clostridium difficile toxin and Giardia lamblia antigen. Cultures and occult blood tests were negative. Oral metronidazole, 500 mg 3 times a day, was administered, and the patient was hydrated. The diarrhea resolved, and patient was discharged on the fourth hospital day. Prior antibiotic therapy is the most common risk factor for C difficile colitis. This patient developed concomitant infection with C difficile and G lamblia while he used ranitidine. He had no other risk factors for these infections. Hence, we propose that ranitidine-induced hypochlorhydria predisposed this patient to the enteric infections.

Influence of anti-Helicobacter triple-therapy with metronidazole, omeprazole and clarithromycin on intestinal microflora

BACKGROUND

Proton pump inhibitor-based therapy including two antibiotics is the treatment of choice for Helicobacter pylori infection. Oral antibiotic treatment can lead to intestinal overgrowth of potentially pathogenic bacteria.

AIM

To investigate the intestinal microflora before and at different times after H. pylori treatment with omeprazole, clarithromycin and metronidazole.

METHODS

Bacterial growth in faecal samples from 51 patients infected with H. pylori was determined qualitatively and quantitatively. During the same period of time, stool samples from 27 H. pylori-negative controls were taken and investigated at the same intervals.

RESULTS

The microflora of H. pylori-infected patients was different from that in H. pylori negative controls. It was characterized by a high concentration of lactobacilli, mainly Lactobacillus acidophilus. Immediately after therapy there was an increased colonization with yeasts, while the growth of lactobacilli and other species was inhibited. Clostridium difficile was cultured from three cases, but without clinical manifestations of pseudomembranous colitis. After 4 weeks of therapy, the microflora returned to normal and was not different from that of the H. pylori-negative control group.

CONCLUSIONS

In H. pylori-positive patients the intestinal flora is characterized by an increase in growth of acid-tolerant L. acidophilus. Eradication therapy exerts only a short-term influence on intestinal flora, whereas in the long term, the intestinal microflora is restored to a pattern similar to that of the control group.