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Lee YJ, Ssekalo I, Kazungu R, Blackwell TS, Muwereza P, Wu Y, Sáenz JB. Community prevalence of Helicobacter pylori and dyspepsia and efficacy of triple therapy in a rural district of eastern Uganda. Heliyon 2022; 8:e12612. [PMID: 36593846 PMCID: PMC9803786 DOI: 10.1016/j.heliyon.2022.e12612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/24/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Background Helicobacter pylori (H. pylori) infection and chronic dyspepsia represent significant medical burdens in the developing world. An accurate assessment of the prevalence of chronic dyspepsia, as well as of the effectiveness of population-based screening and eradication of H. pylori are warranted. Objectives We determined the prevalence of H. pylori and chronic dyspepsia within the general adult population in a region of eastern Uganda. Independent predictors of H. pylori infection were assessed. Finally, we evaluated the efficacy of standard triple therapy on H. pylori eradication. Methods Of 400 randomly selected adult residents in eastern Uganda, 376 were administered a validated, chronic dyspepsia questionnaire and provided a stool sample for H. pylori testing. H. pylori-positive participants were given standard triple therapy and monitored for medication adherence. The efficacy of triple therapy on H. pylori eradication was determined by fecal antigen testing after treatment. Log-linear and logistic regression analyses identified predictors of H. pylori positivity and eradication failure. Results H. pylori prevalence within the study population was 48%. The prevalence of chronic dyspepsia was 87%. The presence or severity of dyspepsia did not predict H. pylori infection. However, a higher level of education was an independent predictor of H. pylori infection. Standard triple therapy resulted in ∼90% eradication. Missing at least four doses of any of the triple therapy medications over the 14-day course predicted eradication failure. Conclusions In our study population, chronic dyspepsia did not predict H. pylori infection, though clinical suspicion for this prevalent pathogen should nonetheless remain high. Population-based screening and adherence to triple therapy are effective at eradicating H. pylori within this region.
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Affiliation(s)
- Yang Jae Lee
- Yale University School of Medicine, New Haven, Connecticut, USA,Empower Through Health, USA
| | - Ibrahim Ssekalo
- University of Tennessee College of Medicine, Memphis, Tennessee, USA
| | | | - Timothy S. Blackwell
- Empower Through Health, USA,University of Tennessee College of Medicine, Memphis, Tennessee, USA
| | | | - Yuefeng Wu
- Department of Mathematics and Computer Science, University of Missouri-St. Louis, St. Louis, Missouri, USA
| | - José B. Sáenz
- Division of Gastroenterology, Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA,Corresponding author.
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Prevalence of Helicobacter pylori among Patients with Gastrointestinal Tract (GIT) Symptoms: A Retrospective Study at Selected Africa Air Rescue (AAR) Clinics in Kampala, Uganda, from 2015 to 2019. J Trop Med 2021; 2021:9935142. [PMID: 34790241 PMCID: PMC8592774 DOI: 10.1155/2021/9935142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 10/07/2021] [Indexed: 11/27/2022] Open
Abstract
Background Helicobacter pylori (HP) infection is extremely common worldwide, with almost half of the world's population infected. In Uganda, no study has been done on the trends of the prevalence of H. pylori infection in the affluent population. Therefore, this retrospective cross-sectional study aimed at determining the trend of H. pylori prevalence among affluent patients presenting with gastrointestinal (GIT) symptoms whose stool samples were tested at selected AAR clinics in Kampala area. Patients were tested for Helicobacter pylori infection using the stool antigen test between January 2015 and December 2019. Results The overall 5-year H. pylori prevalence was 35.7% (1298/3634). The prevalence was higher in males (36.0% (736/2044)) than in females (35.4% (562/1590)), although not statistically significant (OR = 0.97, p = 0.680, 95% CI: 0.84–1.11). The prevalence of H. pylori infection was significantly higher (39.4%) among patients who belonged to the age group of 19–35 years (OR = 1.49, p < 0.001, 95% CI: 1.22–1.82). The prevalence for H. pylori among the age group of 19–35, the most productive age, could be attributed to work-related factors such as stress. The highest prevalence (43.4%) was recorded in 2018 and the lowest (21.4%) in 2015; however, the trend of H. pylori infection in the 5 years was fluctuating. Conclusion H. pylori infestation is a preserve of not only the poor but also the elites. Stressful factors, especially in the age group of 19–35 years, should be appropriately managed.
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Clinical Evaluation of a Real-Time PCR Assay for Simultaneous Detection of Helicobacter pylori and Genotypic Markers of Clarithromycin Resistance Directly from Stool. J Clin Microbiol 2021; 59:JCM.03040-20. [PMID: 33536295 DOI: 10.1128/jcm.03040-20] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/02/2021] [Indexed: 12/28/2022] Open
Abstract
Helicobacter pylori infection is mainly diagnosed noninvasively, with susceptibility testing traditionally requiring endoscopy. Treatment is empirical, with clarithromycin-based triple therapy recommended where resistance rates are below 15%. Rising rates of clarithromycin resistance, resulting in high clarithromycin-based therapy failure rates, are seen worldwide, but U.S. data are limited. We developed a real-time PCR assay for simultaneous detection of H. pylori and genotypic markers of clarithromycin resistance directly from stool specimens. The assay was validated by testing 524 stool samples using an H. pylori stool antigen test as the reference method for detection accuracy and Sanger sequencing to confirm genotypic susceptibility results. A separate set of 223 antigen-positive stool samples was tested and retrospective medical record review conducted to define clinical utility. PCR resulted in 88.6% and 92.8% sensitivity in the validation and clinical study sets, respectively. Sequencing confirmed correct detection of clarithromycin resistance-associated mutations in all positive validation samples. The PCR-predicted clarithromycin resistance rate was 39% in the clinical data set overall and 31% in treatment-naive patients; the clarithromycin-based triple therapy eradication rate in treatment-naive patients was 62%. The clarithromycin-based triple therapy success was lower when resistance was predicted by PCR (41%) than when no resistance was predicted (70%; P = 0.03). PCR results were positive in 98% of antigen-positive stools from patients tested for eradication. The described PCR assay can accurately and noninvasively diagnose H. pylori, provide genotypic susceptibility, and test for eradication. Our findings support the need for susceptibility-guided therapy in our region if a clarithromycin-based regimen is considered.
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Diagnostic Accuracy of a Noninvasive Test for Detection of Helicobacter pylori and Resistance to Clarithromycin in Stool by the Amplidiag H. pylori+ClariR Real-Time PCR Assay. J Clin Microbiol 2020; 58:JCM.01787-19. [PMID: 31996442 DOI: 10.1128/jcm.01787-19] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/19/2020] [Indexed: 02/07/2023] Open
Abstract
The noninvasive detection of Helicobacter pylori and its resistance to clarithromycin could revolutionize the management of H. pylori-infected patients by tailoring eradication treatment without any need for endoscopy when histology is not necessary. Several real-time PCR tests performed on stools have been proposed, but their performances were either poor or they were tested on too few patients to be properly evaluated. We conducted a prospective, multicenter study including 1,200 adult patients who were addressed for gastroduodenal endoscopy with gastric biopsies and who were naive for eradication treatment in order to evaluate the performance of the Amplidiag H. pylori+ClariR assay recently developed by Mobidiag (Espoo, Finland). The results of the Amplidiag H. pylori+ClariR assay performed on DNA from stools (automatic extraction with the EasyMag system [bioMérieux]) were compared with those of culture/Etest and quadruplex real-time PCRs performed on two gastric biopsy samples (from the antrum and corpus) to detect the H. pylori glmM gene and mutations in the 23S rRNA genes conferring clarithromycin resistance. The sensitivity and specificity of the detection of H. pylori were 96.3% (95% confidence interval [CI], 92 to 98%) and 98.7% (95% CI, 97 to 99%), respectively. The positive and negative predictive values were evaluated to be 92.2% (95% CI, 92 to 98%) and 99.3% (95% CI, 98 to 99%), respectively. In this cohort, 160 patients (14.7%) were found to be infected (positive by culture and/or PCR). The sensitivity and specificity for detecting resistance to clarithromycin were 100% (95% CI, 88 to 100%) and 98.4% (95% CI, 94 to 99%), respectively.
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Smith S, Fowora M, Pellicano R. Infections with Helicobacter pylori and challenges encountered in Africa. World J Gastroenterol 2019; 25:3183-3195. [PMID: 31333310 PMCID: PMC6626727 DOI: 10.3748/wjg.v25.i25.3183] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/02/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023] Open
Abstract
Helicobacter pylori (H. pylori) is the causative agent of gastritis, peptic ulcer disease, mucosa associated lymphoid tissue lymphoma and gastric cancer (GC). While this bacterium infects 50% of the world’s population, in Africa its prevalence reach as high as 80% as the infection is acquired during childhood. Risk factors for H. pylori acquisition have been reported to be mainly due to overcrowding, to have infected siblings or parent and to unsafe water sources. Despite this high H. pylori prevalence there still does not exist an African guideline, equivalent to the Maastricht V/Florence Consensus Report of the European Helicobacter and Microbiota Study Group for the management of this infection. In this continent, although there is a paucity of epidemiologic data, a contrast between the high prevalence of H. pylori infection and the low incidence of GC has been reported. This phenomenon is the so-called “African Enigma” and it has been hypothesized that it could be explained by environmental, dietary and genetic factors. A heterogeneity of data both on diagnosis and on therapy have been published. In this context, it is evident that in several African countries the increasing rate of bacterial resistance, mainly to metronidazole and clarithromycin, requires continental guidelines to recommend the appropriate management of H. pylori. The aim of this manuscript is to review current literature on H. pylori infection in Africa, in terms of prevalence, risk factors, impact on human health, treatment and challenges encountered so as to proffer possible solutions to reduce H. pylori transmission in this continent.
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Affiliation(s)
- Stella Smith
- Department of Molecular Biology and Biotechnology, Nigerian Institute of Medical Research, Lagos PMB 2013, Nigeria
| | - Muinah Fowora
- Department of Molecular Biology and Biotechnology, Nigerian Institute of Medical Research, Lagos PMB 2013, Nigeria
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Westerik N, Reid G, Sybesma W, Kort R. The Probiotic Lactobacillus rhamnosus for Alleviation of Helicobacter pylori-Associated Gastric Pathology in East Africa. Front Microbiol 2018; 9:1873. [PMID: 30154777 PMCID: PMC6102400 DOI: 10.3389/fmicb.2018.01873] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/25/2018] [Indexed: 12/16/2022] Open
Abstract
The probiotic Lactobacillus rhamnosus GG (LGG) can play a role in establishing a harmless relationship with Helicobacter pylori and reduce gastric pathology in East African populations. H. pylori has the ability to inhabit the surface of the mucous layer of the human stomach and duodenum. In the developing world, an estimated 51% of the population is carrier of H. pylori, while in some Western countries these numbers dropped below 20%, which is probably associated with improved sanitation and smaller family sizes. Colonization by H. pylori can be followed by inflammation of the gastric mucus layer, and is a risk factor in the development of atrophic gastritis, peptic ulcers and gastric cancer. Notwithstanding the higher prevalence of H. pylori carriers in developing countries, no equal overall increase in gastric pathology is found. This has been attributed to a less pro-inflammatory immune response to H. pylori in African compared to Caucasian populations. In addition, a relatively low exposure to other risk factors in certain African populations may play a role, including the use of non-steroidal anti-inflammatory drugs, smoking, and diets without certain protective factors. A novel approach to the reduction of H. pylori associated gastric pathology is found in the administration of the probiotic bacterium Lactobacillus rhamnosus yoba 2012 (LRY), the generic variant of LGG. This gastro-intestinal isolate inhibits H. pylori by competition for substrate and binding sites as well as production of antimicrobial compounds such as lactic acid. In addition, it attenuates the host's H. pylori-induced apoptosis and inflammation responses and stimulates angiogenesis in the gastric and duodenal epithelium. The probiotic LRY is not able to eradicate H. pylori completely, but its co-supplementation in antibiotic eradication therapy has been shown to relieve side effects of this therapy. In Uganda, unlike other African countries, gastric pathology is relatively common, presumably resulting from the lack of dietary protective factors in the traditional diet. Supplementation with LRY through local production of probiotic yogurt, could be a solution to establish a harmless relationship with H. pylori and reduce gastric pathology and subsequent eradication therapy treatment.
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Affiliation(s)
- Nieke Westerik
- Department of Molecular Cell Biology, VU University Amsterdam, Amsterdam, Netherlands
- Yoba for Life Foundation, Amsterdam, Netherlands
| | - Gregor Reid
- Canadian R&D Centre for Human Microbiome and Probiotics, Lawson Health Research Institute, London, ON, Canada
- Department of Microbiology and Immunology, and Surgery, Western University, London, ON, Canada
| | | | - Remco Kort
- Department of Molecular Cell Biology, VU University Amsterdam, Amsterdam, Netherlands
- Yoba for Life Foundation, Amsterdam, Netherlands
- Department of Microbiology and Systems Biology, Netherlands Organization for Applied Scientific Research, Zeist, Netherlands
- ARTIS-Micropia, Amsterdam, Netherlands
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Flores-Treviño S, Mendoza-Olazarán S, Bocanegra-Ibarias P, Maldonado-Garza HJ, Garza-González E. Helicobacter pylori drug resistance: therapy changes and challenges. Expert Rev Gastroenterol Hepatol 2018; 12:819-827. [PMID: 29976092 DOI: 10.1080/17474124.2018.1496017] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Helicobacter pylori is a Gram-negative bacterium that causes chronic gastritis, dyspepsia, peptic ulcers, and gastric cancer. Over half the world's population is infected with H. pylori, with higher prevalence in developing countries. Areas covered: In this review, current guidelines on H. pylori therapy, such as the Toronto consensus statement, the Maastricht V/Florence consensus report, and the American College of Gastroenterology guidelines, are compared. Also, we analyzed reports of antimicrobial resistance of H. pylori published in PubMed in the last years to determine current antimicrobial resistance worldwide. Expert commentary: Although H. pylori antimicrobial resistance varies by geographic area, its prevalence has been increasing over time, causing therapy failures and low eradication rates. To best optimize the management of H. pylori infection, H. pylori therapy should be based on patterns of local and individual antimicrobial resistance, if possible.
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Affiliation(s)
- Samantha Flores-Treviño
- a Hospital Universitario Dr. José Eleuterio González y Facultad de Medicina, Servicio de Gastroenterología,Nuevo León , Universidad Autónoma de Nuevo León , Monterrey , México
| | - Soraya Mendoza-Olazarán
- a Hospital Universitario Dr. José Eleuterio González y Facultad de Medicina, Servicio de Gastroenterología,Nuevo León , Universidad Autónoma de Nuevo León , Monterrey , México
| | - Paola Bocanegra-Ibarias
- a Hospital Universitario Dr. José Eleuterio González y Facultad de Medicina, Servicio de Gastroenterología,Nuevo León , Universidad Autónoma de Nuevo León , Monterrey , México
| | - Héctor Jesús Maldonado-Garza
- a Hospital Universitario Dr. José Eleuterio González y Facultad de Medicina, Servicio de Gastroenterología,Nuevo León , Universidad Autónoma de Nuevo León , Monterrey , México
| | - Elvira Garza-González
- a Hospital Universitario Dr. José Eleuterio González y Facultad de Medicina, Servicio de Gastroenterología,Nuevo León , Universidad Autónoma de Nuevo León , Monterrey , México
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Jaka H, Rhee JA, Östlundh L, Smart L, Peck R, Mueller A, Kasang C, Mshana SE. The magnitude of antibiotic resistance to Helicobacter pylori in Africa and identified mutations which confer resistance to antibiotics: systematic review and meta-analysis. BMC Infect Dis 2018; 18:193. [PMID: 29699490 PMCID: PMC5921563 DOI: 10.1186/s12879-018-3099-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 04/17/2018] [Indexed: 12/19/2022] Open
Abstract
Background Worldwide Helicobacter pylori (H.pylori) treatment is of great challenge due to increased antibiotic resistance. The burden of H. pylori antibiotic resistance in Africa is high with unclear information regarding the real magnitude. This systematic review and meta-analysis was conducted to investigate the magnitude of H.pylori antibiotic resistance in Africa to gain insight of the extent of the problem among H.pylori naïve treatment patients. Method The search was performed in the academic databases, Embase, PubMed, Web of Science and Africa Wide Information. ProQuest Dissertation and Theses, Scopus, Ethos, Africa Index Medicus (WHO), BioMed Central Proceedings, BASE, British Library, Open grey, Library of Congress and the New York Academy of Grey Literature Report were additionally searched for grey literature. Published articles from Africa on H.pylori antibiotic resistance between 1986 and June 2017 were systematically reviewed to estimate the H. pylori extent of resistance to macrolides, quinolones, amoxicillin, tetracycline and metronidazole. Results In 26 articles a total of 2085 isolates were tested for metronidazole, 1530 for amoxicillin, 1277 for tetracycline, 1752 for clarithromycin and 823 for quinolones.The overall pooled proportion of H.pylori resistance to quinolones, clarithromycin, tetracycline, metronidazole and amoxicillin were: (17.4%, 95%CI 12.8 - 21.9), (29.2%, 95%CI:26.7-31.8), (48.7%, 95%CI: 44.5-52.9), (75.8%, 95% CI: 74.1-.77.4) and (72.6%, 95% CI: 68.6-76.6), respectively. The commonest mutation detected were A2143G (49/97) for clarithromycin, RdxA (41/56) for metronidazole and D87I (16/40) for quinolones. Conclusion Prevalence of metronidazole, clarithromycin, and amoxicillin resistance is high in developing world including Africa. This could impair the first line triple therapy of the H.pylori infection. There is a need of conducting surveillance of H.pylori susceptibility pattern in Africa for dual and triple resistance which can be used for the empirical treatment. Electronic supplementary material The online version of this article (10.1186/s12879-018-3099-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hyasinta Jaka
- Gastroenterology and Hepatology Unit, Weill Bugando School of Medicine, Catholic University of Heath and Allied Sciences and Bugando Hospital Mwanza, P.O. BOX 1464, Mwanza, Tanzania.
| | | | - Linda Östlundh
- National Medical Library, United Arab Emirates University, Abu Dhabi, United Arab Emirates
| | - Luke Smart
- Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA
| | - Robert Peck
- Gastroenterology and Hepatology Unit, Weill Bugando School of Medicine, Catholic University of Heath and Allied Sciences and Bugando Hospital Mwanza, P.O. BOX 1464, Mwanza, Tanzania.,Center for Global Health, Weill Cornell Medicine, New York, NY, USA
| | | | | | - Stephen E Mshana
- Department of Microbiology and Immunology, Weill Bugando School of Medicine, Catholic University of Heath and Allied Sciences Mwanza, Mwanza, Tanzania
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Papastergiou V, Mathou N, Licousi S, Evgenidi A, Paraskeva KD, Giannakopoulos A, Stavrou PZ, Platsouka E, Karagiannis JA. Seven-day genotypic resistance-guided triple Helicobacter pylori eradication therapy can be highly effective. Ann Gastroenterol 2018; 31:198-204. [PMID: 29507466 PMCID: PMC5825949 DOI: 10.20524/aog.2017.0219] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 10/30/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The efficacy and applicability of molecular testing to guide the selection of antibiotics in triple Helicobacter pylori (H. pylori) eradication regimens have not been reported. We tested a 7-day, genotypic resistance-guided triple H. pylori eradication therapy in a high-resistance setting. METHODS Consecutive dyspeptic patients with H. pylori infection were prospectively enrolled. Genotypic resistances to clarithromycin (23SrRNA mutations) and fluoroquinolones (gyrA mutations) were determined from gastric biopsy specimens using a commercially available molecular assay (GenoTypeâ HelicoDR). A tailored genotypic resistance-guided 7-day triple therapy comprised esomeprazole, amoxicillin, and either clarithromycin (wild-type 23SrRNA), levofloxacin (23SrRNA mutated/wild-type gyrA) or rifabutin (both 23SrRNA/gyrA mutated). H. pylori eradication was confirmed by 13C-urea breath test. RESULTS Of 148 subjects screened, 51 patients were enrolled (male/female: 27/24, mean age: 50.7±11.4 years, treatment-naïve/-experienced: 32/19). The molecular kit was easily implemented, allowing for rapid (within 24 h) and relatively inexpensive determination of H. pylori resistance (clarithromycin: 47.1%, fluoroquinolones: 15.7%, dual clarithromycin/fluoroquinolones: 7.8%). For patients who received clarithromycin-, levofloxacin- and rifabutin-containing triple therapy, the respective eradication rates were 24/27, 20/20, and 2/4 by intention-to-treat (ITT); and 24/24, 19/19 and 2/3 by per-protocol (PP) analysis. Overall eradication rates were 90.2% (95% confidence interval [CI] 77.8-96.3%) by ITT and 97.8% (95%CI 87-99.8%) by PP analysis, showing no significant difference between treatment-naïve and -experienced patients (ITT: 87.5% vs. 94.7%, P=0.64; PP: 96.4% vs. 100%, respectively, P=1.00). CONCLUSIONS Regardless of prior treatment history, a genotypic resistance-guided 7-day triple therapy, based on a simple molecular assay, achieved a high H. pylori eradication rate.
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Affiliation(s)
- Vasilios Papastergiou
- Department of Gastroenterology (Vasilios Papastergiou, Nicoletta Mathou, Aikaterini Evgenidi, Konstantina D. Paraskeva, Athanasios Giannakopoulos, Pinelopi-Zoi Stavrou, John A. Karagiannis), Athens, Greece
| | - Nicoletta Mathou
- Department of Gastroenterology (Vasilios Papastergiou, Nicoletta Mathou, Aikaterini Evgenidi, Konstantina D. Paraskeva, Athanasios Giannakopoulos, Pinelopi-Zoi Stavrou, John A. Karagiannis), Athens, Greece
| | - Sophia Licousi
- Department of Microbiology (Sophia Licousi, Evangelia Platsouka), General Hospital of Nea Ionia “Konstantopouleio-Patission”, Athens, Greece
| | - Aikaterini Evgenidi
- Department of Gastroenterology (Vasilios Papastergiou, Nicoletta Mathou, Aikaterini Evgenidi, Konstantina D. Paraskeva, Athanasios Giannakopoulos, Pinelopi-Zoi Stavrou, John A. Karagiannis), Athens, Greece
| | - Konstantina D. Paraskeva
- Department of Gastroenterology (Vasilios Papastergiou, Nicoletta Mathou, Aikaterini Evgenidi, Konstantina D. Paraskeva, Athanasios Giannakopoulos, Pinelopi-Zoi Stavrou, John A. Karagiannis), Athens, Greece
| | - Athanasios Giannakopoulos
- Department of Gastroenterology (Vasilios Papastergiou, Nicoletta Mathou, Aikaterini Evgenidi, Konstantina D. Paraskeva, Athanasios Giannakopoulos, Pinelopi-Zoi Stavrou, John A. Karagiannis), Athens, Greece
| | - Pinelopi-Zoi Stavrou
- Department of Gastroenterology (Vasilios Papastergiou, Nicoletta Mathou, Aikaterini Evgenidi, Konstantina D. Paraskeva, Athanasios Giannakopoulos, Pinelopi-Zoi Stavrou, John A. Karagiannis), Athens, Greece
| | - Evangelia Platsouka
- Department of Microbiology (Sophia Licousi, Evangelia Platsouka), General Hospital of Nea Ionia “Konstantopouleio-Patission”, Athens, Greece
| | - John A. Karagiannis
- Department of Gastroenterology (Vasilios Papastergiou, Nicoletta Mathou, Aikaterini Evgenidi, Konstantina D. Paraskeva, Athanasios Giannakopoulos, Pinelopi-Zoi Stavrou, John A. Karagiannis), Athens, Greece
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