Randomized Clinical Trial Comparing Concomitant and Tailored Therapy for Eradication of Helicobacter pylori Infection

Rapid diagnosis and precision treatment of Helicobacter pylori infection in clinical settings

Helicobacter pylori is a gram-negative bacterium that colonizes the stomach of approximately half of the worldwide population, with higher prevalence in densely populated areas like Asia, the Caribbean, Latin America, and Africa. H. pylori infections range from asymptomatic cases to potentially fatal diseases, including peptic ulcers, chronic gastritis, and stomach adenocarcinoma. The management of these conditions has become more difficult due to the rising prevalence of drug-resistant H. pylori infections, which ultimately lead to gastric cancer and mucosa-associated lymphoid tissue (MALT) lymphoma. In 1994, the International Agency for Research on Cancer (IARC) categorized H. pylori as a Group I carcinogen, contributing to approximately 780,000 cancer cases annually. Antibiotic resistance against drugs used to treat H. pylori infections ranges between 15% and 50% worldwide, with Asian countries having exceptionally high rates. This review systematically examines the impacts of H. pylori infection, the increasing prevalence of antibiotic resistance, and the urgent need for accurate diagnosis and precision treatment. The present status of precision treatment strategies and prospective approaches for eradicating infections caused by antibiotic-resistant H. pylori will also be evaluated.

Molecular Characterization and Mutational Analysis of Clarithromycin- and Levofloxacin-Resistance Genes in Helicobacter pylori from Gastric Biopsies in Southern Croatia

Point mutations in the 23S rRNA, gyrA, and gyrB genes can confer resistance to clarithromycin (CAM) and levofloxacin (LVX) by altering target sites or protein structure, thereby reducing the efficacy of standard antibiotics in the treatment of Helicobacter pylori infections. Considering the confirmed primary CAM and LVX resistance in H. pylori infected patients from southern Croatia, we performed a molecular genetic analysis of three target genes (23S rRNA, gyrA, and gyrB) by PCR and sequencing, together with computational molecular docking analysis. In the CAM-resistant isolates, the mutation sites in the 23S rRNA gene were A2142C, A2142G, and A2143G. In addition, the mutations D91G and D91N in GyrA and N481E and R484K in GyrB were associated with resistance to LVX. Molecular docking analyses revealed that mutant H. pylori strains with resistance-related mutations exhibited a lower susceptibility to CAM and LVX compared with wild-type strains due to significant differences in non-covalent interactions (e.g., hydrogen bonds, ionic interactions) leading to destabilized antibiotic-protein binding, ultimately resulting in antibiotic resistance. Dual resistance to CAM and LVX was found, indicating the successful evolution of H. pylori resistance to unrelated antimicrobials and thus an increased risk to human health.

Current role of tailored therapy in treating Helicobacter pylori infections. A systematic review, meta-analysis and critical analysis

BACKGROUND AND AIMS

Recent guidelines dictate that all Helicobacter pylori (H. pylori) infected subjects should receive curative therapy. The efficacy of empirical regimens for H. pylori eradication might decline with bacterial, drug, and host factors. The necessity of a tailored therapy still remains controversial. Here we provide a meta-analysis of the current status of susceptibility-based (tailored) therapy in which susceptibility-based therapies were compared to the currently accepted choice of empiric therapy. In this rapidly closing era, neither the susceptibility nor empiric therapies were routinely optimized, such that we report the outcome of comparisons on the efficacy of unoptimized tailored vs. locally preferred empiric treatments.

METHODS

PubMed, Medline, and Embase databases were searched using suitable keywords. Individual and pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the fixed- or random-effects model as appropriate. Heterogeneity was calculated employing the Cochrane Q test and I² values, whereas the possibility of publication bias was examined by constructing funnel plots. Additionally, subgroup and sensitivity analyses were performed.

RESULTS

Thirty-four studies were included with a total of 9613 patients. Tailored therapy proved superior to empiric treatment [OR 2.07 (95% CI 1.53-2.79)]. However, tailored therapy achieved eradication rates >90% in only 15 (44%) studies and >95% in only 6 (17.6%).

CONCLUSIONS

Although tailored therapy performed better than empiric treatment, the lack of optimization of therapies failed to reliably achieve high cure rates (>90%). These results emphasize that H. pylori infection, like other infectious diseases, should utilize the principles of antimicrobial stewardship in relation to treatment guidance.

Personalized Approach in Eradication of Helicobacter pylori Infection

The increase in antibiotic resistance to Helicobacter pylori (H. pylori) is associated with a decrease in the effectiveness of eradication therapy. Although some success has been achieved by adjusting therapeutic regimens according to local data on resistance to certain antibiotics, a new approach is needed to ensure a better therapeutic response. Tailored therapy, based on sensitivity tests to antibiotics, is increasingly proving to be a superior therapeutic option, even as a first-line therapy. Moreover, the recently published Maastricht VI guidelines emphasize utilizing a susceptibility-guided strategy in respect to antibiotic stewardship as the first choice for eradication therapy. In addition, polymerase chain reaction (PCR) technology is becoming a standard tool in the diagnosis of H. pylori infections through non-invasive testing, which further optimizes the eradication process. We provide a review regarding the current position of the individualized approach in eradication therapy and its future prospects. Based on novel understandings, the personalized approach is an effective strategy to increase the successful eradication of H. pylori infections.

Tailored therapy for Helicobacter pylori eradication: A systematic review and meta-analysis

Background: Due to an increase in drug resistance, the eradication rate of H. pylori with empirical therapy has declined. Tailored therapy has been proposed as an alternative to standard empirical treatments. The necessity of personalized eradication therapy remains unclear. The aim of this study was to determine whether tailored therapy is superior to empirical therapy for H. pylori infection.

Methods: We searched for eligible randomized controlled trials in the PubMed, Embase (Ovid), Wanfang, and Cochrane Central Register of Controlled Trials databases up to 10 December 2021. A random effects model comparing pooled relative risks (RRs) with 95% confidence intervals (CIs) was applied in the meta-analysis.

Results: Twenty-one studies were included in the meta-analysis. In the first-line treatment, tailored therapy was more effective than empirical therapy (RR, 1.14 [95% CI, 1.08–1.21], I² = 72.2%). In the second-line therapy setting, the results did not reveal significant differences between the two treatments (RR, 1.05 [95% CI, 0.84–1.30], I² = 80.6%). A similar result was observed in mixed second- and third-line treatments (RR, 1.03 [95% CI, 0.96–1.11], I² = 0.0%). Regarding adverse events, no significant differences were found between the two treatments (RR, 0.90 [95% CI, 0.80–1.01], I² = 35.7%). Most of the results were highly heterogeneous.

Conclusion: A tailored approach might provide a better eradication rate than empirical methods in first-line treatment. There might be no obvious advantage in second-line or mixed second- and third-line treatments third-line treatment. Due to the high heterogeneity, the results should be interpreted with caution. Further clinical studies are needed and justified.

Helicobacter pylori Infection in Croatian Population: Knowledge, Attitudes and Factors Influencing Incidence and Recovery

Basic and clinical knowledge about Helicobacter pylori infections has been improved in the past. However, the translation of this knowledge into public health intervention has remained poor. A survey based cross-sectional study was performed to assess the factors regarding the H. pylori infection in the general population. The survey was conducted using a previously developed questionnaire, adapted for the population in Croatia. Respondents (N = 1131) had a good knowledge score with a median of 4 out of 5 correct answers (interquartile range: 2–4). Senior participants had a lower frequency of high knowledge answers about H. pylori (43.1%) compared to younger (56.1%) and middle-aged participants (51.5%, p = 0.014). Rural participants had a higher frequency of low knowledge answers compared to urban and suburban ones (21.7% vs. 9.5% and 9.4%, p = 0.011). Only 315 participants (27.9%) were screened for the H. pylori infection, despite high support for the screening programs among the untested (74.7%) and tested (85.7%). Habits of smoking (p = 0.036) and coffee drinking (p = 0.008) were associated with more symptoms after eradication therapy. Further education is needed for the groups at risk for H. pylori infection, especially to raise the awareness of the importance of screening programs. More research is warranted to assess the effects of dietary changes on therapy outcomes.

Characteristics of Helicobacter pylori Heteroresistance in Gastric Biopsies and Its Clinical Relevance

Background

Antimicrobial susceptibility testing (AST) plays a vital role in anti-Helicobacter pylori treatment, but the traditional AST method has difficulty detecting heteroresistance, which may cause an increased prevalence of resistant strains and eradication failure.

Aims

To investigate the characteristics of heteroresistance in H. pylori in gastric biopsies and investigate its clinical relevance.

Method

A total of 704 gastric biopsies were selected for 23S rRNA and gyrA gene sequencing, 470 H. pylori isolates from these biopsies were selected for AST, and the clinical characteristics of the patients were reviewed.

Result

For the 699 biopsies that were positive for 23S rRNA gene, 98 (14.0%) showed a heteroresistance genotype, and a wild type (WT) combined with A2143G (86.7%) genotype was found in most samples. For the 694 biopsies that were positive for gyrA gene, 99 (14.3%) showed a heteroresistance genotype, and a WT combined with 87K (26.3%) or WT combined with 91N (23.2%) genotype was predominant. According to the E-test results, the resistance rates of heteroresistance genotype samples for clarithromycin and levofloxacin were 36.2% and 68.1%, respectively. When dividing the heteroresistance samples into different groups according to the sequencing profile peaks of the mutation position, the resistance rates were higher along with mutation peaks at the mutation position. In addition, patients infected with mutated or heteroresistant strains showed lower peptic ulcer detection rates than those infected with the WT strain (p < 0.05).

Conclusion

Heteroresistance genotypes for clarithromycin and levofloxacin were not rare in H. pylori. Most cases with a heteroresistance genotype showed a susceptible phenotype for clarithromycin and a resistance phenotype for levofloxacin. Patients infected with heteroresistance genotype strains showed a lower peptic ulcer detection rate than those infected with the WT strain.