Is Helicobacter pylori antibiotic resistance surveillance needed and how can it be delivered?

Abstract

Summary Background Most patients are prescribed Helicobacter pylori treatment without culture and antibiotic susceptibility testing, as current guidance recommends that patients with recurrent dyspepsia should be tested for H. pylori using a non‐invasive breath or faecal antigen test. Aims To determine the prevalence of H. pylori antibiotic resistance in patients attending endoscopy in England and Wales, and the feasibility of an antibiotic resistance surveillance programme testing. Methods We tested the antibiotic susceptibility of H. pylori isolates from biopsy specimens from 2063 of 7791 (26%) patients attending for endoscopy in Gloucester and Bangor, and 339 biopsy specimens sent to the Helicobacter Reference Unit (HRU) in London. Culture and susceptibility testing was undertaken in line with National and European methods. Results Helicobacter pylori were cultured in 6.4% of 2063 patients attending Gloucester and Bangor hospitals. Resistance to amoxicillin, tetracycline and rifampicin/rifabutin was below 3% at all centres. Clarithromycin, metronidazole and quinolone resistance was significantly higher in HRU (68%, 88%, 17%) and Bangor isolates (18%, 43%, 13%) than Gloucester (3%, 22%, 1%). Each previous course of these antibiotics is associated with an increase in the risk of antibiotic resistance to that agent [clarithromycin: RR = 1.5 (P = 0.12); metronidazole RR = 1.6 (P = 0.002); quinolone RR = 1.8 (P = 0.01)]. Conclusions Helicobacter pylori infection is now uncommon in dyspeptic patients at endoscopy. A surveillance system is feasible and necessary to inform dyspepsia management guidance. Clinicians should take a thorough antibiotic history before prescribing metronidazole, clarithromycin or levofloxacin for H. pylori.

Extremely High Prevalence of Metronidazole-Resistant Helicobacter pylori Strains in Mountain People (Karen and Hmong) in Thailand

“…The low prevalence of AMX resistance (0.8%) and no resistance to TET (0%) were compatible with previous studies from many countries. [12][13][14] Fluoroquinolone resistance was present in 27.3% of Hmong people and possibly reflects the common use of CIP for diarrheal disease in this group.…”

Letter: surveillance of Helicobacter pylori antibiotic resistance – authors' reply

“…More aggressive therapy is indicated in patients who have symptomatic or severe hyponatraemia, and treatment should include restriction of sodium and water intake. 2,3 The vasopressin receptor antagonists, vaptans, produce a selective water diuresis without affecting sodium and potassium excretion. In patients with advanced cirrhosis and ascites, hypervolaemic hyponatraemia occurs as a result of a decrease in effective circulating volume (ECV).…”

“…In northern European countries, this degree of resistance would be unusual. 2 However, it is becoming increasingly common in southern European countries, and the recent Maastricht guidance no longer recommends a proton pump inhibitor (PPI) with clarithromycin and metronidazole as first-line treatment. 3 We were very surprised by the very high resistance rates to amoxicillin and tetracycline, as this is highly unusual and therefore it would be interesting to have further work done on these isolates.…”

Letter: surveillance of Helicobacter pylori antibiotic resistance

“…1 The authors have issued very important data regarding Helicobacter pylori antibiotic resistance in patients attending for endoscopy in England and Wales. Culture and susceptibility testing based therapies seem to be the most logical step to overcome the problem of resistant strains, but, as described by the authors, culture can turn out to be negative, even in the presence of a positive urease test.…”