Eradication of Helicobacter Pylori in Iran: A Review

An Update on Eradication of Helicobacter Pylori in Iran: A Review

Background

Helicobacter pylori, the most prevalent infection in the world, has great importance due to being related to peptic ulcer disease, gastric metaplasia, dysplasia, and even gastric adenocarcinoma or mucosa-associated lymphoid tissue (MALT) lymphoma. The standard H. pylori eradication regimen is based on antibiotic susceptibility testing. If susceptibility testing is not available, a standard treatment regimen will be recommended based on records of H. pylori resistance rates to antibiotics in a region or locally proven highly effective regimens (equal to or higher than 90% eradication rate). The aim of this review was to define suitable recommendations for local treatment in different cities of Iran.

Methods

This review article consists of randomized controlled trials related to H. pylori eradication in Iran. Data including the kind of therapy, number of patients and per-protocol H. pylori eradication rates were recorded in data gathering forms. Data search was conducted in PubMed and Google Scholar databases from 2018 to December 2023.

Results

According to our review of Iranian articles regarding first-line H. pylori eradication regimens, these treatment protocols could be recommended: Bismuth-clarithromycin quadruple therapy in Ardabil, bismuth-clarithromycin quadruple therapy with probiotics in Birjand, standard triple therapy in Ilam, bismuth quadruple therapy or bismuth triple therapy or concomitant regimen in Sari, sequential therapy in Tehran and bismuth quadruple therapy in Yazd. These regimes can be extended to other regions that have a similar situation. According to the reports of Iranian researchers, a quinolone-containing regimen (levofloxacin preferred) is recommended for second-line eradication therapy.

Conclusion

Various H. pylori eradication regimens can be used as first-line therapy; however, choices for second-line therapy are limited. We recommend the quinolone-containing regimens as the preferred second-line therapy.

Comparison of the Efficacy of 12-day Concomitant Quadruple Therapy versus 14-day High dose Dual Therapy as a First-line H. pylori Eradication Regimen

Background/Aims

Helicobacter pylori (H. pylori) is the most prevalent infection in the world and is strongly associated with gastric adenocarcinoma, lymphoma and gastric or duodenal ulcers. Different regimens have been used for H. pylori eradication. We aimed to compare the efficacy of two different regimens as first-line H. pylori eradication regimens, in an area with high antibiotic resistance.

Methods

In this RCT, we assigned 223 patients with H. pylori infection, who were naïve to treatment. They were randomly divided into two groups to receive either 12-day concomitant quadruple therapy (consisting of pantoprazole 40 mg, amoxicillin 1 g, clarithromycin 500 mg, and metronidazole 500 mg every 12 hours) or 14-day high dose dual therapy (consisting of esomeprazole 40 mg and amoxicillin 1 g TDS). H. pylori eradication was assessed eight weeks after the end of treatment.

Results

H. pylori eradication rate by PP analysis for 12-day concomitant quadruple therapy and 14-day high dose dual therapy were 90.4% and 79.1%, respectively (p=0.02). According to ITT analysis, the eradication rates were 86.2% and 76.3%, respectively (p=0.06). Adverse drug reactions were 12.3% in high dose dual therapy and 36.8% in concomitant quadruple therapy (p<0.001).

Conclusions

Twelve-day concomitant therapy seems to be an acceptable regimen for first-line H. pylori eradication in Iran, a country with a high rate of antibiotic resistance. Although, high dose dual therapy did not result in an ideal eradication rate, but it had fewer drug side effects than the 12-day concomitant regimen.

Targeted delivery of a short antimicrobial peptide (CM11) against Helicobacter pylori gastric infection using concanavalin A-coated chitosan nanoparticles

Helicobacter pylori is the cause of most cases of stomach ulcers and also causes some digestive cancers. The emergence and spread of antibiotic-resistant strains of H. pylori is one of the most important challenges in the treatment of its infections. The present study aims to develop a concanavalin A (ConA) coated chitosan (CS) nanocarrier-based drug delivery for the targeted release of peptides to the site of H. pylori infection. Accordingly, chitosan was used as an encapsulating agent for CM11 peptide delivery by applying ionotropic gelation method. Con-A was used for coating CS nanoparticles to target H. pylori. The CS NPs and ConA-CS NPs were characterized by FTIR, dynamic light scattering (DLS), and scanning electron microscopy (SEM). The MIC of CM11-loaded ConA-CS NPs against H. pylori SS1 strain was analyzed in vitro. In order to evaluate the treatment efficiency in vivo, a gastric infection model of H. pylori SS1 strain was established in mice and histopathological studies and IL-1β cytokine assay were performed. Based on the results, the size frequency for CS NPs and ConA-CS NPs was about 200 and 350 nm, respectively. The prepared CM11-loaded ConA-CS NPs exhibited antibacterial activity against H. pylori SS1 strain with a concentration of 32 µg/ml. The highest healing process was observed in synthesized CM11-loaded ConA-CS NPs treatments and a significant decrease in IL-1β was observed. Our findings highlight the potential of chitosan nanoparticles as a drug delivery vehicle in the treatment of gastric infection model of H. pylori SS1 strain.

Gastric troubles in Iran: The role of social and economic factors in Helicobacter pylori infection

Background

Helicobacter pylori infection is a major risk factor for gastric cancer in Iran, but the impact of socioeconomic factors on its prevalence is poorly understood. This study aimed to assess the socioeconomic inequalities and risk factors associated with H. pylori infection in Iran.

Methods

This cross-sectional study was conducted based on the PERSIAN cohort study. A total of 20460 individuals aged 35 to 70 years in Ardabil, Iran were included in the study. H. pylori infection was determined based on stool tests and clinical records. Multilevel logistic regression models with random intercepts at household and community levels were used to identify risk factors associated with H. pylori prevalence. The concentration index (CIn) and concentration curve (CC) were employed to assess socioeconomic-related inequality.

Results

In this study, 70.4% (CI 69.6-71.0) of the participants were infected with H. pylori, with a higher prevalence in women (71.2%) than men (69.6%). Age (OR: 1.37, CI: 1.17-1.61), sex (OR: 1.20, CI: 1.12-1.28), level of education (OR: 1.33, CI: 1.17-1.49), cardiac disease (OR: 1.32, CI:1.18-1.46), and BMI groups (OR: 2.49, CI: 1.11-5.58) were significantly associated with H. pylori infection based on the multivariable logistic regression. The results of the CIn and CC indicated that H. pylori were more prevalent among economically disadvantaged groups (CIn: -0.1065; [-0.1374 to -0.0755]).

Conclusion

The prevalence of H. pylori in Iran is higher than in other developing countries, and significant socioeconomic inequality exists between the poor and the rich. To reduce the rate of gastric cancer, socio-economic and demographic factors, especially the poor and people with low levels of education, should be considered.

A Population-Based Cross-sectional Study on the Prevalence and Associated Risk Factors of Helicobacter pylori Infection in Rafsanjan, a Low Gastric Cancer Area in Southeast Iran

Background: Despite all improvements in sanitation and exposure to antibiotics over time, Helicobacter pylori (HP) prevalence remains high, affecting the lives of about half of the world population, which can gradually lead to serious upper gastrointestinal disorders. Understanding HP's epidemiologic patterns help us to better manage the burden of this infection and to plan more effectively regarding potential screening or eradication strategies. We, therefore, aimed to report the crude and age- and sex-standardized prevalence rate of HP infection, its trend, and possible associated factors among asymptomatic healthy individuals in Rafsanjan city, a low-incidence area of gastric cancer (GC) in the southeast of Iran, from July 2018 to December 2021. Methods: This population-based cross-sectional descriptive study included 2,046 male and female subjects between 3 to 72 years who were in good health condition. Study participants were randomly selected from the Health Houses and each underwent a questionnaire-based interview and provided blood and feces samples. The presence of HP infection was detected by serum IgG antibodies and stool antigen test. Results: The overall and age- and sex-standardized prevalence rates of HP infection were 50.9% and 43%, respectively. The prevalence rate has notably decreased in all age groups compared with 2007. Also, it was significantly higher among men (P=0.033) and increased with advancing age (P<0.001). A higher population density living in a specific room area (P=0.012) increased the likelihood of HP infection. Conclusion: To conclude, the prevalence of HP infection is decreasing over time in Rafsanjan city, which may be due to improvements in living standards in this area. A healthy lifestyle and adherence to hygienic principles, especially during childhood, may be required for a reduction in the prevalence of HP infection.

Association of Helicobacter pylori Infection with Papillary Thyroid Carcinoma: A Case-control Study

Background: The thyroid nodules incidence has risen worldwide. Although factors such as increasing the use of imaging techniques and more rapid detection of small thyroid nodules have been implicated in the recent rise in thyroid cancer incidence, some environmental parameters such as infectious agents may be involved. Helicobacter pylori infection is an environmental risk factor, which may mimic the antigenic properties of membranes of thyrocytes. Objectives: This study aimed at evaluating the association of H. pylori infection with benign and malignant thyroid nodules in comparison with the control group. Methods: Patients with benign thyroid nodules, papillary thyroid cancer (PTC), and euthyroid healthy controls without thyroid nodules that had just been diagnosed were included in the study. All participants underwent clinical examination. Various biochemical parameters such as serum H. pylori Ab (IgG) and thyroid function tests were measured. Comparisons were made between groups. Results: Finally, 370 patients with benign thyroid nodules, 364 patients with PTC, and 360 healthy subjects without nodules participated as a control group. In the patients with PTC, the prevalence of H. pylori infection was 89.6%, while in the group of patients with benign thyroid nodules and the control group was 81.1% and 75%, respectively (P < 0.001). Helicobacter pylori antibody (Ab) titer was not significantly associated with any of the anthropometric and biochemical variables. Conclusions: Helicobacter pylori infection was significantly higher in patients with benign thyroid nodules and PTC than in the control group. Also, the rate of infection was significantly higher in the malignant nodule group than in the benign thyroid nodules group.

Antibiotic resistance pattern of Helicobacter pylori strains isolated from patients in Isfahan, Iran

Background

The objective of this study was to evaluate the antibiotic resistance pattern of Helicobacter pylori strains isolated from patients in Isfahan province.

Materials and Methods

Gastric antrum biopsy specimens of patients undergoing endoscopy were cultured. The samples with the growth of H. pylori underwent antibiotic susceptibility test by disk diffusion method.

Reaults

Of 96 samples, 50 samples (53%) were positive for H. pylori. The rates of antibiotic resistance were as follows: amoxicillin, 6%; azithromycin, 20%; furazolidone, 22%; levofloxacin, 16%; metronidazole, 20%; rifampin, 12%; and tetracycline, 22%.

Conclusion

H. pylori strains in our area have high rates of resistance to azithromycin, levofloxacin, metronidazole, tetracycline, and furazolidone.

Efficacy of 14-day concomitant quadruple therapy and 14-day high-dose dual therapy on H. pylori eradication

Aim

We compared the efficacy of two different regimens for H. pylori eradication in areas with high antibiotic resistance.

Background

Helicobacter pylori (H. pylori) is a gram-negative bacillus that has a strong association with chronic gastritis and peptic ulcer disease. Different regimens with varying degrees of effectiveness have been used for H. pylori eradication.

Methods

The current randomized controlled trial (RCT) randomly assigned 217 patients who had indications for H. pylori eradication therapy to two groups. One group were administered concomitant quadruple therapy (pantoprazole 40 mg, amoxicillin 1 gr, clarithromycin 500 mg, and metronidazole 500 mg every 12 hours) for 14 days, and the second group received 14 days of high-dose dual therapy, consisting of esomeprazole 40 mg BID and amoxicillin 1g TDS. H. pylori eradication was assessed eight weeks after the end of treatment.

Results

H. pylori eradication rates by PP analysis for 14 days concomitant quadruple therapy and high-dose dual therapy were 88.6% (95% CI, 80.3-92.8) and 82.2% (95% CI, 74.8-89.5), respectively (p = 0.19). According to intention-to-treat (ITT) analysis, the eradication rates were 81.6% (95% CI, 74.5-88.6) and 80.6% (95% CI, 73-88.1), respectively (p = 0.58). Overall drug side effects were 20.8% in high-dose dual therapy and 49.6% in concomitant quadruple therapy (p < 0.001).

Conclusion

Fourteen days concomitant quadruple therapy can be considered as a relatively acceptable regimen for H. pylori eradication in areas with high clarithromycin and metronidazole resistance. It seems that high-dose dual therapy could be a promising alternative regimen in these areas.

Levofloxacin-based therapy as an efficient alternative for eradicating Helicobacter pylori infection in Iran: a systematic review and meta-analysis

OBJECTIVES

Despite excessive resistance of Helicobacter pylori to clarithromycin among Iranian population, unfortunately, clarithromycin-based therapy is still prescribed in Iran. Recent studies have shown high rates of H. pylori eradication in patients treated with levofloxacin. The main purpose of this study was to compare the effect of levofloxacin with clarithromycin on the eradication of H. pylori infection in Iranian population.

METHODS

A comprehensive meta-analysis was done for the relevant cohort studies and clinical trials to compare the therapeutic effects of levofloxacin with clarithromycin in Iranian population. We pooled the data using odds ratio corresponding to 95% confidence intervals to find the clinical efficacy of levofloxacin versus clarithromycin to treat H. pylori infection. The heterogeneity and publication bias were also measured for the included studies.

RESULTS

A total of 13 studies were included in the quantitative synthesis. Eradication rate in patients receiving levofloxacin and clarithromycin were 75% and 66.3%, respectively (OR: 1.76; 95% CI: 1.40-2.20). In addition, in the subgroup analysis, it was confirmed that cure rate is relatively higher in levofloxacin-treated cases. However, there is significant heterogeneity as well as publication bias, thus, the results need to be interpreted with caution.

CONCLUSIONS

We found that the success of levofloxacin treatment was significantly higher than that of clarithromycin. Therefore, it is suggested that clarithromycin-based triple therapy be replaced by levofloxacin-based triple therapy in countries with high resistance rate to clarithromycin such as Iran. Nevertheless, findings of the present study need to be approved with larger investigation on Iranian population.

Prevalence of Helicobacter Pylori Infection in Patients with Dyspepsia in North of Iran

BACKGROUND Dyspepsia is a common complaint among patients who refer to gastroenterology clinics. Studies have shown that there is a strong relationship between dyspepsia and Helicobacter pylori (HP) infection. We have investigated the prevalence of HP infection in patients with dyspepsia and its correlation with age and socioeconomic status (SES) of patients in Mazandaran province, northern Iran. METHODS In this cross-sectional study, patients with dyspepsia who had undergone upper gastrointestinal endoscopy were enrolled. Diagnosis of HP infection was according to the results of rapid urease test (RUT), and Giemsa staining of pathology samples. A questionnaire including endoscopic findings, demographic data, and SES information was completed for each patient. RESULTS The mean age of the 614 patients was 45.8±5 years, and 60% of them were female. Most patients had normal endoscopy (56.1%), and gastric ulcer and erosion was the most common abnormal endoscopic finding (24.7%). The prevalence of HP infection in patients with dyspepsia was about 66.6%. HP infection was associated with a lower prevalence in people aged below 30 years and good SES. CONCLUSION The prevalence of HP infection in patients with dyspepsia was 66.6%. In addition, HP infection rate was lower in people under the age of 30 years and patients with good SES.

The increasing antimicrobial resistance of Helicobacter pylori in Iran: A systematic review and meta-analysis

BACKGROUND

Antimicrobial resistance of Helicobacter pylori can result in eradication failure. Metadata on the antimicrobial resistance of H pylori in Iran could help to formulate H pylori eradication strategies in Iran.

METHODS

A systematic review was performed after searching in MEDLINE, Scopus, Embase, Web of Science, and the Cochrane Library. A meta-analysis was performed, and a comparison of the rates between children and adults; time periods (1999-2010, 2011-2016, 2017-2019); and the methods used was carried out.

RESULTS

A total of 66 studies investigating 5936 H pylori isolates were analyzed. The weighted pooled resistance (WPR) rates were as follows: clarithromycin 21% (95% CI 16-26), metronidazole 62% (95% 57-67), clarithromycin in combination with metronidazole 16% (95% CI 10-23), ciprofloxacin 24% (95% CI 15-33), levofloxacin 18% (95% CI 9-30), erythromycin 29% (95% CI 12-50), furazolidone 13% (95% CI 4-27), tetracycline 8% (95% CI 5-13), and amoxicillin 15% (95% CI 9-22). During the three time periods, there was an increased resistance to amoxicillin, clarithromycin, ciprofloxacin, furazolidone, and tetracycline (P ˂ .05). Furazolidone and a clarithromycin/metronidazole combination had the higher resistance rates in children (P ˂ .05).

CONCLUSION

An increasing rate of resistance to amoxicillin, clarithromycin, ciprofloxacin, furazolidone, and tetracycline in Iranian H pylori isolates was identified. In children, the resistance to furazolidone and a combination of clarithromycin and metronidazole is higher compared to adults. As a stable, high resistance to metronidazole was found in children and adults in all Iranian provinces, we suggest that metronidazole should not be included in the Iranian H pylori eradication scheme.

Using next-generation sequencing to analyze Helicobacter pylori clones with different levofloxacin resistances from a patient with eradication failure

The regimens containing levofloxacin (LVX) have been recommended as an alternate to standard triple therapy to treat Helicobacter pylori infections and H pylori mixed infection always lead to H pylori chronic infection. Although the molecular mechanism of LVX resistance with gyrA gene mutation has been clearly understood in H pylori, other genes involved in antibiotic resistance remain unclear. Efflux pump plays an important role in clinically relevant multidrug resistance. Furthermore, the relationship between the strains with different LVX level-resistances from individuals is also unknown.Helicobacter pylori monoclonal strains were isolated from patients with eradication failure. E test was used to detect the minimal inhibitory concentration of LVX. One lower-level LVX-resistant clone and 2 higher-level LVX-resistant clones from the same patient were selected to sequence the complete genomes. Single-nucleotide variants (SNVs) and mutations were extracted and analyzed from gryA and resistance-nodulation-division family efflux genes.Two clones with higher-level resistance had the mutation pattern of Asn87Lys and one lower-level LVX-resistant clone had an Asp91Asn mutation. Compared to clones with higher-level resistance, the higher genetic variations were found in genes belonging to the resistance-nodulation-division family in H pylori strains with lower-level resistance to LVX. There were significantly more SNVs of Hp0970 (hefE) and Hp1329 (hefI) in the lower-level LVX-resistant clone than those in the higher-level LVX-resistant clones (P = .044).The mutation pattern of the Asn87Lys of the gyrA gene confers a higher resistance to LVX than that of the Asp91Asn in H pylori. Increase in the number of SNVs of the Hp0970 (hefE) and Hp1329 (hefI) genes change the resistance to LVX. Twelve mutations verified by Sanger sequencing in Hp0970 (hefE) and Hp1329 (hefI) may decrease resistant levels to LVX.

Formula Diet Alters the Ileal Metagenome and Transcriptome at Weaning and during the Postweaning Period in a Porcine Model

Exclusive breastfeeding impacts the intestinal microbiome and is associated with a better immune function than is seen with milk formula (MF) feeding in infants and yet with mechanisms poorly defined. The porcine model was used to evaluate the impact of MF on ileum microbial communities and gene expression relative to human milk (HM)-fed piglets. Fifty-two Dutch Landrace male piglets were fed an isocaloric diet of either HM (n = 26) or MF (n = 26) from day 2 through day 21 of age and weaned to a solid diet until day 51. Eleven piglets from each group were euthanized at day 21, while the remaining piglets (HM, n = 15; MF, n = 15) were euthanized at day 51 to collect ileal epithelium (EP) scrapings and ileal (IL) tissues. The epithelial mucosa was subjected to shotgun metagenome sequencing, and EP and IL tissues were used for transcriptome analysis. On day 21, transcriptome data revealed that the levels of pathways involved in inflammation and apoptosis were significantly higher in MF piglets than in HM piglets, whereas the levels of tight junctions and pathogen detection systems were lower in MF piglets than in HM piglets. The MF impacts on the small intestine were maintained over the postweaning period (day 51) as indicated by higher levels of Dialister invisus bacteria and higher levels of expression of genes associated with inflammation and apoptosis pathways relative to HM group. The current study demonstrated that MF might impact local intestinal inflammation, apoptosis, and tight junctions and might suppress pathogen recognition in the small intestine compared with HM.IMPORTANCE Exclusive human milk (HM) breastfeeding for the first 6 months of age in infants is recommended to improve health outcomes during early life and beyond. When women are unable to provide sufficient HM, milk formula (MF) is often recommended as a complementary or alternative source of nutrition. Previous studies in piglets demonstrated that MF alters the gut microbiome and induces inflammatory cytokine production. The links between MF feeding, gut microbiome, and inflammation status are unclear due to challenges associated with the collection of intestinal samples from human infants. The current report provides the first insight into MF-microbiome-inflammation connections in the small intestine compared with HM feeding using a porcine model. The present results showed that, compared with HM, MF might impact immune function through the induction of ileal inflammation, apoptosis, and tight junction disruptions and likely compromised immune defense against pathogen detection in the small intestine relative to piglets that were fed HM.

A Comparison between 10-day and 12-day Concomitant Regimens for Helicobacter Pylori Eradication: A Randomized Clinical Trial

BACKGROUND

Helicobacter pylori (H. pylori) infection is one of the most common bacterial infections worldwide, which is associated with peptic ulcer disease and gastric cancer. In this study, we compared the efficacy of 10-day versus 12-day concomitant therapy as the first-line treatment for H. pylori eradication in Iran.

METHODS

218 patients with peptic ulcer disease and naïve H. pylori infection, were randomly divided into two groups to receive either 10-day or 12-day concomitant regimens, composed of pantoprazole 40 mg, amoxicillin 1000 mg, clarithromycin 500 mg, and metronidazole 500 mg, all given twice daily. Eight weeks after treatment, H. pylori eradication was assessed by 14C- urea breath test. The trial was registered in the Iranian Registry of Clinical Trials (code: IRCT20170521034070N2).

RESULTS

212 patients completed the study. According to the intention to treat analysis, the eradication rates were 83.6% (95% CI: 76.6-90.5) and 88.8% (95% CI: 82.8-94.7) in 10-day and 12-day concomitant therapy groups, respectively (p = 0.24). Per-protocol eradication rates were 85.9% (95% CI: 79.3–92.4) and 92.6% (95% CI: 87.6–97.5), respectively (p = 0.19). The rates of severe side effects were not statistically different between the two groups (3.6% vs. 8.1%; p = 0.428).

CONCLUSION

12-day concomitant therapy could achieve ideal eradication rates by both intention to treat and perprotocol analyses. In order to reduce the cost of drugs and the rate of adverse effects of therapy, among 10-day and 12day regimens, 12-day concomitant therapy seems to be a good alternative to 14-day concomitant therapy that has been suggested by international guidelines.

Helicobacter pylori antibiotic resistance and correlation with cagA motifs and homB gene

Objectives: Helicobacter pylori (H. pylori) infection caused by antibiotic-resistant strains represents a major public health threat that aggressively promotes gastric cancer progression. Antibiotic resistance evaluation is immensely important to counteract its emergence. Here we merely determine the prevalence of antibiotic resistance in H. pylori isolates and its correlation with cagA motifs and the homB gene. Methods: The antibiotic resistance pattern was investigated on 128 H. pylori isolated strains utilizing the disk diffusion method and study the correlation between it and the presence of pathogenic genes, cagA EPIYA motifs and homB gene, were accurately detected using the PCR. Results: The resistance rates to four antibiotics were 70.1% for metronidazole, 35.5% for amoxicillin, 7.2% for clarithromycin and 8.2% for tetracycline. Resistance phenotypes were separated into two groups, single resistance (63.2%) and multi-resistance (12.5%). The prevalence of cagA-ABCC resistant strains and homB⁺ resistant strains was significantly higher in cancer (p = 0.04 and p = 0.01, respectively) than those of other diseases. The prevalence of cagA-homB ⁺ resistance strains was 21.8% and had a significant correlation with PUD. A significant relationship was observed between amoxicillin resistant rate with ABC-homB (p = 0.0006). Conclusion: The Resistance rate to selected antibiotics in Shiraz is higher than years ago. The presence of cagA-homB ⁺ is associated with antibiotic resistance and also homB can be used as a marker to antibiotic resistance status prediction in H. pylori isolated in this area.

The Comparison of Levofloxacin- and Clarithromycin-Based Bismuth Quadruple Therapy Regimens in Helicobacter pylori Eradication

OBJECTIVE

The aim of the current study was to compare the efficacy of quadruple therapy including levofloxacin and clarithromycin for Helicobacter pylori eradication.

METHODS

This clinical trial study was conducted on 189 patients with H. pylori infection who underwent gastroscopy and stomach biopsy in Shahid Beheshti Hospital, Kashan, Iran. After classification of patients, one group was treated with bismuth subcitrate (120 mg, 2 tablet/12 h), omeprazole (20 mg/12 h), amoxicillin (1 g/12 h), and clarithromycin (500 mg/12 h) and other group with bismuth subcitrate (120 mg, 2 tablet/12 h), omeprazole (20 mg/12h), amoxicillin (1 g/12 h), and levofloxacin (500 mg/12 h) for 2 weeks. After the end of the antibiotic treatment, omeprazole therapy was continued for 4 weeks. Two weeks after discontinuation of omeprazole, fecal antigen test was performed for both the groups to confirm the eradication of H. pylori infection.

FINDINGS

The success of H. pylori eradication in the levofloxacin and clarithromycin groups was observed in 78 (89.7%) and 71 (69.6%) patients, respectively (P < 0.01). A significant difference was also seen between the two groups in terms of side effects and its incidence (P < 0.01), so that the incidence of side effect types in the clarithromycin group was more than the levofloxacin group except muscular pain and fatigue (P < 0.01).

CONCLUSION

Levofloxacin-based quadruple regimen therapy was superior to clarithromycin-based quadruple regimens regarding H. pylori eradication and side effects. Therefore, the levofloxacin-based regimen can be considered as an effective treatment for the first-line anti-H. pylori therapy.

Molecular Assessment of Resistance to Clarithromycin in Helicobacter pylori Strains Isolated from Patients with Dyspepsia by Fluorescent In Situ Hybridization in the Center of Iran

Background and Aims

Helicobacter pylori is a common infectious bacterium mostly found in gastroduodenal diseases. The increased prevalence of clarithromycin-resistant H. pylori strains is a major challenge in the successful treatment of infections caused by this organism. The present study is aimed at detecting the clarithromycin resistance pattern of H. pylori strains isolated from gastric biopsies and evaluating point mutations of the 23S rRNA gene. Patients and methods. In the present descriptive cross-sectional study, 165 patients with gastrointestinal disorders, who were referred to the Endoscopy Center of Dr. Shariati Hospital of Isfahan, Iran, were enrolled from April to July 2018. H. pylori infection was diagnosed by culture, and susceptibility of the isolates to clarithromycin was assessed by the E-test. Minimum inhibitory concentration (MIC) values were obtained based on EUCAST recommendations. Also, fluorescence in situ hybridization (FISH) was used to determine point mutations associated with clarithromycin resistance.

Results

By using culturing, H. pylori was isolated from 50.3% (83/165) gastric biopsy specimens. The overall frequency of resistance to clarithromycin was 25.3% (21/83) by the E-test. In the resistance genotypic analysis, 19 isolates had mutations. The prevalence of A2143G and A2144G mutations was 68.4% (13/19) and 31.5% (6/19), respectively. A2143C mutation was not tracked in any isolate. Two isolates with MIC > 0.5 μg/mL had no mutations that could be related to other mechanisms of resistance.

Conclusion

As presented in the study, the high prevalence of clarithromycin-resistant H. pylori due to point mutations of the 23S rRNA gene indicates the necessity of revising the standard treatment regimen based on antibiotic susceptibility pattern of each region.

Significance of TC9 and TH9 in Helicobacter pylori-induced gastritis

BACKGROUND

H pylori plays a critical role in the development of stomach cancer, especially in people affected by the bacteria at an early stage of life. Th9 cells and IL-9 play major roles in immune responses against various infections. IL-9 is influential in chronic or acute inflammation of the mucosa.

AIM

This study seeks to investigate the possible functions of Tc9, Th9 cells, and IL-9 level in patients with inflammation due to H pylori infection.

METHODS

Eighty-three patients with dyspepsia symptoms and twenty normal subjects with no sign and symptoms of dyspepsia were recruited. Frequencies of T-cell subsets were determined by flow cytometry. Levels of cytokines IL-9 family in the sera and supernatants of antigen-activated PBMCs patients were measured by ELISA and flow cytometry.

RESULTS

The participants included 56 females and 47 males with a mean age of 39.2 ± 15.3 years. We assigned the infected group into peptic ulcer and gastritis (chronic active and chronic). Frequencies of Tc9, Th17, Tc17, Th17/9, and Tc17/9 increased significantly in the peptic ulcer, chronic active, and chronic gastritis, compared with the uninfected and healthy control groups. A significant increase was seen in IL-9, IL-4, and IL-23 in the chronic active gastritis. Further observed was a significant increase in IL-21 and a decrease in IL-10 in the infected groups.

CONCLUSION

The results revealed that increased Tc9, Th17/9, and Tc17/9 cells appear to be influential in the progression and severity of H pylori infection. Also, increased IL-9 and IL-4 levels and Tc9, Tc17/9, and Th17/9 were seen in chronic active gastritis patients. These findings may provide useful information for a therapeutic targeting of chronic active H pylori infections.

Comparing the Efficacy of Sequential and Standard Quadruple Therapy for Eradication of H. Pylori Infection

BACKGROUND

The aim of this study was comparison the effectiveness of sequential and standard quadruple therapy on eradication of H. pylori infection.

METHODS

This clinical trial study was conducted on 160 patients with dyspepsia or gastroduodenal ulcer. Patients were randomly divided into two groups. Group A (standard regimen) received omeprazole, amoxicillin, clarithromycin and bismuth subcitrate for 2 weeks. Group B (sequential regimen) received omeprazole and amoxicillin in 5 days and omeprazole, tinidazole and levofloxacin in 5 days. After the end of treatment regimens, 20 mg omeprazole was administered twice daily for 3 weeks. H. pylori eradication was assessed 2 months after antibiotic treatment via fecal antigen.

RESULTS

Frequency of H. pylori eradication in group A and B was observed in 55 (68.8%) and 63 patients (78.8%), respectively. No significant difference was seen between two groups, regarding H. pylori eradication (p = 0.15). The most common side effects in group A, B were bitterness of mouth (63.8%) and nausea (16.2%), respectively (p H. pylori infection, higher rate of H. pylori eradication was seen in group B than group A. Thus, sequential regimen was a more appropriate regimen with fewer complications.

Efficacy and tolerability of fourteen-day sequential quadruple regimen: pantoprazole, bismuth, amoxicillin, metronidazole and or furazolidone as first-line therapy for eradication of Helicobacter pylori: a randomized, double-blind clinical trial

The optimal pharmacological regimen for eradication of Helicobacter pylori (H. pylori) has been investigated for many years. This study aimed to evaluate the efficacy and tolerability of bismuth-based quadruple therapy (B-QT) and a modified sequential therapy (ST) regimens in eradication of H. pylori. A randomized, double-blind trial was conducted on 344 patients. Patients with H. pylori infection and without a history of previous treatment were randomized to receive 14-day B-QT (bismuth subcitrate 240 mg, pantoprazole 40 mg, amoxicillin 1000 mg, and clarithromycin 500 mg twice daily) or 14-day ST (bismuth subcitrate 240 mg, pantoprazole 40 mg, amoxicillin 1000 mg, and metronidazole 500 mg twice a day for seven days followed by bismuth subcitrate 240 mg, pantoprazole 40 mg, amoxicillin 1000 mg, and furazolidone 100 mg twice a day for additional seven days). Drug adverse effects were assessed during the study. H. pylori eradication was determined eight weeks after the end of treatment using ¹⁴C-urea breath test. Based on per-protocol and intention-to-treat, the eradication rate was significantly higher (p<0.05) in the B-QT regimen 91.9 % (95 % CI; 88.1-94.0) and 90.2 % (95 % CI; 86.3-92.9), respectively compared to the ST regimen 80.8 % (95 % CI; 76.6-84.9) and 78.1 % (95 % CI; 73.7-82.4), respectively. The severity of vomiting and loss of appetite were significantly higher in ST regimen (p<0.05). The B-QT regimen was more effective and safer than the ST regimen. Conclusively, it is suggested to assess the efficacy and safety of this regimen in longer studies, larger population, and in other communities.

Comparison of Levofloxacin-Based, 10-day Sequential Therapy with 14-day Quadruple Therapy for Helicobacter Pylori Eradication: A Randomized Clinical Trial

BACKGROUND

Considering the importance of Helicobacter pylori (H. pylori) eradication, this clinical trial was designed to prospectively evaluate the efficacy of levofloxacin-based, sequential therapy in comparison with quadruple therapy for eradicating H. pylori.

METHODS

Overall 156 patients with dyspepsia and H. pylori infection were included in this study and were randomly allocated to either 10-day sequential therapy group (group A) to receive pantoprazole (40 mg twice daily), amoxicillin (1 gr twice daily), levofloxacin (500 mg twice daily), and tinidazole (500 mg twice daily) (PALT) or 14-day quadruple therapy group (group B) to receive pantoprazole, clarithromycin, bismuth subcitrate, and amoxicillin (PABC). At the end of the study the eradication rate in each group was assessed by urea breath test (UBT).

RESULTS

Age range of the participants was 18-65 years (average 36.9 years) and 50% of them (78 patients) were men. 78 patients were allocated to group A and 78 patients to groupe B. After antibiotic therapy, all the patients received acid suppression therapy with Proton Pump Inhibitor (PPI) for 4 weeks and then the eradication rate was confirmed by UBT (Heli FAN plus 13C, Germany). Before performing UBT, all the participants were requested to halt consumption of PPI for at least 1 week. During the treatment there was not any major complication but in group A (sequential therapy), two patients complained of minor complications including musculoskeletal pain. None of the patients in group B had any complaint or side effect. The rate of H. pylori eradication in group A was 78.2% (61 patients) while this rate in group B was 83.3% (65 patients) with no significant difference between the two groups (p = 0.42). In subgroup analysis, the rate of eradication among men in group A and B were 76.9% and 89.7%, respectively (p = 0.22) while the eradication rate among women were 79.4% and 76.9%, respectively (p = 1.00).

CONCLUSION

It seems that levofloxacin base sequential therapy does not have any advantage in comparison with quadruple regimen and until finding any more effective short course therapy for H. Pylori eradication; we encourage quadruple regimen to be used as the first line therapy.

Helicobacter pylori and its relationship with variations of gut microbiota in asymptomatic children between 6 and 12 years

Objective

To determine the variations in the composition of the intestinal microbiota in asymptomatic children infected with Helicobacter pylori in comparison with children without the infection.

Results

Children infected with H. pylori doubled their probability of presenting 3 of 9 genera of bacteria from the gut microbiota, including: Proteobacteria (p = 0.008), Clostridium (p = 0.040), Firmicutes (p = 0.001) and Prevotella (p = 0.006) in comparison to patients without the infection. We performed a nutritional assessment and found that growth stunting was statistically significantly higher in patients infected with H. pylori (p = 0.046).

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3565-5) contains supplementary material, which is available to authorized users.