Antimicrobial resistance of Helicobacter pylori in Germany, 2015 to 2018

OBJECTIVES

National and international guidelines recommend empiric first-line treatments of individuals infected with Helicobacter pylori without prior antimicrobial susceptibility testing. For this reason, knowledge of primary resistance to first-line antibiotics such as clarithromycin is essential. We assessed the primary resistance of H. pylori in Germany to key antibiotics by molecular genetic methods and evaluated risk factors for the development of resistance.

METHODS

Gastric tissue samples of 1851 yet treatment-naïve H. pylori-positive patients were examined with real-time PCR or PCR and Sanger sequencing for mutations conferring resistance to clarithromycin, levofloxacin and tetracycline. Clinical and epidemiological data were documented and univariable and multivariable logistic regression analyses were conducted.

RESULTS

Overall primary resistances were 11.3% (210/1851) to clarithromycin, and 13.4% (201/1497) to levofloxacin; resistance to tetracycline (2.5%, 38/1497) was as low as combined resistance to clarithromycin/levofloxacin (2.6%, 39/1497). Female sex and prior antimicrobial therapies owing to unrelated bacterial infections were risk factors for clarithromycin resistance (adjusted OR (aOR) 2.3, 95% CI 1.6-3.4; and 2.6, 95% CI 1.5-4.5, respectively); older age was associated with levofloxacin resistance (aOR for those ≥65 years compared with those 18-35 years: 6.6, 95% CI 3.1-14.2).

CONCLUSIONS

Clarithromycin might still be recommended in first-line eradication therapies in yet untreated patients, but as nearly every tenth patient may carry clarithromycin-resistant H. pylori it may be advisable to rule out resistance ahead of treatment by carrying out susceptibility testing or prescribing an alternative therapy.

Natural transformation competence in Helicobacter pylori is mediated by the basic components of a type IV secretion system

Helicobacter pylori (Hp), a Gram-negative bacterial pathogen and aetiologic agent of gastroduodenal disease in humans, is naturally competent for genetic transformation. Natural competence in bacteria is usually correlated with the presence of type IV pili or type IV pilin-like proteins, which are absent in Hp. Instead, we recently identified the comB operon in Hp, carrying four genes tentatively designated as orf2, comB1, comB2 and comB3. We show here that all ComB proteins and the 37-amino-acid Orf2 peptide display significant primary sequence and structural homology/identity to the basic components of a type IV secretion apparatus. ComB1, ComB2 and ComB3, now renamed ComB8, ComB9 and ComB10, correspond to the Agrobacterium tumefaciens VirB8, VirB9 and VirB10 proteins respectively. The peptide Orf2 carries a lipoprotein motif and a second cysteine residue homologous to VirB7, and was thus designated ComB7. The putative ATPase ComB4, encoded by the open reading frame hp0017 of strain 26695, corresponds to virB4 of the A. tumefaciens type IV secretion system. A Hp comB4 transposon insertion mutant was totally defective in natural transformation. By complementation of a Hp DeltacomB deletion mutant, we demonstrate that each of the proteins from ComB8 to ComB10 is absolutely essential for the development of natural transformation competence. The putative lipoprotein ComB7 is not essential, but apparently stabilizes the apparatus and modulates the transformation efficiency. Thus, pathogenic type I Hp strains contain two functional independent type IV transport systems, one for protein translocation encoded by the cag pathogenicity island and one for uptake of DNA by natural transformation. The latter system indicates a possible novel mechanism for natural DNA transformation in bacteria.

Genetic competence in Helicobacter pylori: mechanisms and biological implications

Helicobacter pylori is naturally competent for genetic transformation. The comB locus, consisting of the open reading frames orf2, comB1, comB2, and comB3, is involved in natural transformation competence. Homologies of the ComB proteins with components of the type IV secretion apparatus (VirB9 and VirB10) from the Ti plasmid of Agrobacterium tumefaciens, as well as proteins involved in conjugation of plasmids RP1 and RP4, suggest a similar organization of DNA import (transformation) in H. pylori with well-known DNA export systems.

Genetic and functional characterization of the alpAB gene locus essential for the adhesion of Helicobacter pylori to human gastric tissue

In this study, we isolated and characterized a chromosomal locus of Helicobacter pylori previously identified by transposon shuttle mutagenesis as being involved in the adhesion of the pathogen to gastric epithelial cells. Two closely homologous genes were identified, designated as alpA and alpB, encoding outer membrane (OM) proteins of 518 amino acids each. They are members of the outer membrane protein supergene family identified in the H. pylori 26695 complete genome sequence. AlpA carries a functional lipoprotein signal sequence. AlpB carries a putative standard N-terminal signal sequence and shows a strong amino-acid sequence identity to AlpA. Transposon insertion mutagenesis, immunoblotting and primer extension studies indicate that both genes are organized in an operon, but no obvious consensus promoter sequence was found upstream of the transcriptional start site. The C-terminal portion of both proteins is predicted to form a porin-like beta-barrel in the outer membrane, consisting of 14 transmembrane amphipathic beta-strands. Adhesion experiments with defined isogenic mutants indicate that both proteins are necessary for specific adherence of H. pylori to human gastric tissue. The pattern of AlpAB-dependent adherence of H. pylori to the gastric epithelial surface shows a clear difference to the BabA2-mediated adherence to Lewis, suggesting that a different receptor is involved.

Performance evaluations of physician executives. Interview by Barbara J. Linney

Six senior physician executives were interviewed to see how they were doing or not doing performance reviews in their organizations. There seems to be a trend toward doing them, but it is in the beginning stages. Of the physician executives surveyed, the experience ranges from formal lengthy evaluations with rating scales to reviewing a short list of goals. Several are in the process of developing new systems or revising old ones. Probably the most useful part of a performance evaluation is the conversation between the physician executive and the person he or she reports to. If you can stop approaching performance evaluations as passing negative judgments on people, but as having a conversation to hear their concerns, learn what their goals are, and offer ways to help them achieve their potential, they can be useful, enjoyable experiences for both people.

Natural competence for DNA transformation in Helicobacter pylori: identification and genetic characterization of the comB locus

The gram-negative bacterial pathogen Helicobacter pylori, an important aetiological agent of gastroduodenal disease in humans, belongs to a group of bacterial species displaying competence for genetic transformation. Here, we describe the comB gene locus of H. pylori involved in DNA transformation competence. It consists of a cluster of four tandemly arranged genes with partially overlapping open reading frames, orf2, comB1, comB2 and comB3, constituting a single transcriptional unit. Orf2 encodes a 37-amino-acid peptide carrying a signal sequence, whereas comB1, comB2 and comB3 produce 29 kDa, 38 kDa and 42 kDa proteins, respectively, as demonstrated by immunoblotting with specific antisera. For Orf2 and ComB1, no homologous proteins were identified in the database. For ComB3, the best homologies were found with TraS/TraB from the Pseudomonas aeruginosa conjugative plasmid RP1 and TrbI of plasmid RP4, VirB10 from the Ti plasmid of Agrobacterium tumefaciens and PtlG, a protein involved in secretion of pertussis toxin of Bordetella pertussis. Defined transposon knock-out mutants in individual comB genes resulted in transformation-defective phenotypes ranging from a 90% reduction to a complete loss of the natural transformation efficiency. The comB2 and comB3 genes show homology to HP0528 and HP0527, respectively, located on the cagII pathogenicity island of H. pylori strain 26695.